A patient two days after abdominal surgery suddenly reports that the incision has opened, and loops of bowel are visible. Which action should the nurse take first?
Correct answer: A. Cover the exposed organs with sterile saline dressings
- A. Cover the exposed organs with sterile saline dressings
- B. Place the patient in a high-Fowler position
- C. Attempt to gently replace the organs into the abdomen
- D. Offer oral fluids to prevent dehydration
Explanation
Sterile saline dressings protect the exposed organs from drying and contamination. The nurse then positions the patient with knees flexed, calls for urgent surgical review, and keeps the patient nil by mouth. The organs must never be pushed back into the abdomen.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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