A patient suddenly develops wound separation and abdominal organs are visible through the incision. Which action should the nurse take first?
Correct answer: B. Cover the wound with sterile saline-moistened dressings
- A. Apply a dry gauze dressing and reassess later
- B. Cover the wound with sterile saline-moistened dressings
- C. Push the exposed organs gently back into the abdomen
- D. Place the patient flat and encourage deep breathing
Explanation
The nurse should protect exposed organs with sterile dressings moistened with normal saline and call for urgent medical assistance. Returning the organs to the abdomen can cause tissue injury, and the airway and circulation must also be monitored.
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About Wound Care and Dressings
Wound care covers wound classification, healing stages, assessment of tissue and drainage, pain, infection signs, dressing selection and clean or sterile dressing technique. It also includes pressure injuries by stage and the factors affecting healing, such as nutrition, circulation, diabetes, infection and prolonged pressure.
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