A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?
Cover the wound with sterile, saline-soaked gauze.
Raise the head of the bed to a 45° angle.
Hold gentle, direct pressure on the protruding organ
Place the client's knees in an extended position.
The Correct Answer is A
Covering the wound with sterile, saline-soaked gauze helps to prevent infection and keep the organ moist until surgical repair. Raising the head of the bed, applying pressure, and extending the knees can increase abdominal pressure and worsen the evisceration.
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Naxlex Comprehensive Predictor Exams
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The correct answer is D. The parent should apply pressure with gauze if they see bleeding from the circumcision site, as this can indicate a complication such as infection or dislodgement of the plastic ring. The other statements are incorrect because they can interfere with the healing process or cause harm to the infant. Applying antibiotic ointment can cause irritation or allergic reaction, applying a snug diaper can increase pressure and friction on the penis, and wiping away yellow crusts can remove healthy tissue or cause bleeding .
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