NCLEX-RNReduction of Risk PotentialHard
On postoperative day 3 after abdominal surgery, a client coughs forcefully and reports, "Something just gave way." The nurse observes loops of bowel protruding through the open incision. Which action should the nurse take first?
- ACover the area with sterile saline-soaked gauze, place the client supine with knees bent, and notify the surgeon immediately
- BAttempt to gently push the bowel back into the abdomen
- CAdminister oral fluids and reassess in 15 minutes
- DApply a dry sterile dressing and elevate the head of the bed to 90 degrees
Show answer & explanationAnswer & explanation
Correct answer: A. Cover the area with sterile saline-soaked gauze, place the client supine with knees bent, and notify the surgeon immediately
Wound evisceration, in which abdominal organs protrude through the incision, is a surgical emergency. The nurse should cover the exposed bowel with sterile saline-soaked gauze to keep it moist, position the client supine with knees bent to reduce abdominal tension, keep the client NPO, and notify the surgeon immediately for emergency repair.
Why the other options are wrong
- B. Pushing organs back into the abdomen risks infection and further tissue damage; this should never be attempted.
- C. Oral intake is contraindicated, and delaying notification risks bowel ischemia or further evisceration.
- D. A dry dressing can adhere to and damage exposed bowel tissue, and high Fowler's position increases abdominal pressure on the wound.
Wound Dehiscence and Evisceration
Dehiscence is separation of wound edges; evisceration occurs when abdominal organs protrude through the incision, constituting a surgical emergency.
- Sudden 'give way' sensation with visible bowel protrusion signals evisceration
- Cover exposed organs with sterile saline-soaked gauze immediately
- Position client supine with knees bent to reduce abdominal tension and notify surgeon stat
Memory trick: Wet gauze, bent knees, call the team