CMSRN Medical-Surgical Nursing

Category - Gastrointestinal

Days after abdominal surgery, the client’s wound dehisces. The safest nursing intervention when
this occurs is to _________________.
  1. Cover the wound with sterile, moist saline dressing
  2. Approximate the wound edges with tape
  3. Irrigate the wound with sterile saline
  4. Hold the abdominal contents in place with a sterile gloved hand
Explanation
Answer - A - Cover the wound with a sterile, moist saline dressing. Dehiscence is the partial or complete separation of the surgical wound edges. When this occurs, the client is placed in low Fowler’s position and instructed to lie quietly. The wound should be covered to protect it from exposure and the dressing must be sterile to protect it from infection and moist to prevent the dressing from sticking to the wound, which can disturb the healing process.
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