More Questions on this topic
More Questions on this topic ( 18 Questions)
A nurse is caring for a patient who underwent surgery for appendicitis and has developed wound dehiscence with evisceration on postoperative day 3. What is the priority nursing intervention?
Covering the wound with sterile gauze moistened with normal saline is a correct nursing intervention for wound evisceration, but it is not the priority action. The priority is to get immediate help and inform the surgeon of the situation.
Placing the patient in low Fowler's position with knees bent is another correct nursing intervention for wound evisceration, as it reduces tension on the abdominal muscles and prevents further protrusion of the bowel. However, it is not the priority action either.
Calling for assistance and notifying the surgeon is the priority nursing intervention for wound evisceration, as this is a surgical emergency that requires prompt intervention to prevent complications such as infection, necrosis, or shock. The nurse should also monitor the patient's vital signs and prepare for possible surgery.
Applying pressure to the wound edges is an incorrect nursing intervention for wound evisceration, as it can cause further damage to the bowel and increase the risk of infection. The nurse should avoid touching or manipulating the wound or the bowel.
Choice A reason:
Covering the wound with sterile gauze moistened with normal saline is a correct nursing intervention for wound evisceration, but it is not the priority action. The priority is to get immediate help and inform the surgeon of the situation.
Choice B reason:
Placing the patient in low Fowler's position with knees bent is another correct nursing intervention for wound evisceration, as it reduces tension on the abdominal muscles and prevents further protrusion of the bowel. However, it is not the priority action either.
Choice C reason:
Calling for assistance and notifying the surgeon is the priority nursing intervention for wound evisceration, as this is a surgical emergency that requires prompt intervention to prevent complications such as infection, necrosis, or shock. The nurse should also monitor the patient's vital signs and prepare for possible surgery.
Choice D reason:
Applying pressure to the wound edges is an incorrect nursing intervention for wound evisceration, as it can cause further damage to the bowel and increase the risk of infection. The nurse should avoid touching or manipulating the wound or the bowel.