Practice Quiz

NCLEX-RN

Category - Physiological

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A client calls the attention of the nurse and tells her that his abdominal incision seems to have “ripped apart.” On assessment, the nurse notes that the incision has eviscerated. The initial nursing action after instructing another nurse to call the physician is:
  1. Apply pressure to the wound until the bleeding stops
  2. Securely apply an abdominal binder to support the wound
  3. Cover the wound with a sterile dressing soaked in saline solution
  4. Let the client lie on his back with his legs elevated
Explanation
Answer: C - Once the surgical incision eviscerates, a condition where the layers of the wound are totally separated with the extrusion of internal organs, the initial nursing action is to cover the wound with a sterile saline dressing. This action prevents infections, such as peritonitis. The other options are not appropriate.
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