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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?
- A. Cover the wound with sterile, saline-soaked gauze.
- B. Hold gentle, direct pressure on the protruding organ.
- C. Place the client's knees in an extended position.
- D. Raise the head of the bed to a 45° angle.
Correct Answer: A
Rationale: Covering the wound with sterile, saline-soaked gauze is correct. Evisceration occurs when abdominal contents protrude through a surgical wound. To prevent drying and further tissue damage, the nurse should immediately cover the exposed organs with sterile gauze moistened with saline to maintain moisture and reduce infection risk.
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Correct Answer: A
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Correct Answer: A
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- B. Wear tight-fitting clothing.
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A nurse is caring for a client who has a new prescription for prednisone. Which of the following adverse effects should the nurse monitor for?
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