HESI RN CAT Exit Exam Related

Review HESI RN CAT Exit Exam related questions and content

The nurse is assessing a client who is 2 days post-op following abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?

  • A. Apply a sterile saline dressing to the wound
  • B. Notify the healthcare provider
  • C. Administer pain medication
  • D. Cover the wound with an abdominal binder
Correct Answer: A

Rationale: The correct action for the nurse to take first is to apply a sterile saline dressing to the wound. This is because the client is experiencing evisceration, which is a medical emergency requiring immediate attention to prevent infection and further complications. By applying a sterile saline dressing, the nurse can protect the exposed bowel from contamination, maintain moisture, and promote healing. This action helps to reduce the risk of infection and provides a temporary barrier until further interventions can be implemented.

Summary of Incorrect Choices:
B: Notifying the healthcare provider is important, but immediate action to protect the exposed bowel is the priority.
C: Administering pain medication does not address the primary concern of protecting the exposed bowel.
D: Covering the wound with an abdominal binder does not provide the necessary protection and could potentially exacerbate the situation by applying pressure to the protruding bowel.