Practice Quiz

NCLEX-PN

Category - Physiological Adaptation

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A female client who had an abdominal surgery tells the nurse that after coughing, she felt her abdominal incision come apart. On inspection, the nurse determines that the client’s abdominal wound has eviscerated. The priority action of the nurse is to:
  1. Notify the RN or physician
  2. Cover the evisceration with a moist, sterile dressing
  3. Assist the client in semi-Fowler’s position
  4. Apply manual pressure
Explanation
Answer: B - The most important action of the nurse is to cover the evisceration with a moist, sterile dressing. An open wound increases the client’s risk for infections. The physician or RN should then be notified immediately.
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