Editing Medical-Surgical Nursing – LPN Practice Questions (section)

==Question 14==
While assisting a patient out of bed on the fifth postoperative day, the licensed practical nurse observes that the abdominal wound has separated and a loop of intestine is protruding through the incision. What should the nurse do first?
# Attempt to gently push the intestine back into the abdomen.
# Cover the area with sterile gauze moistened with sterile normal saline and call for help.
# Apply a dry pressure dressing and tape it firmly in place.
# Return the patient to a standing position and walk to the chair as planned.

'''Answer:''' Option 2, cover the area with sterile gauze moistened with sterile normal saline and call for help.

''Rationale:'' This is evisceration, a surgical emergency. Moist sterile coverings keep the exposed tissue from drying out and reduce contamination. The nurse also places the patient in low Fowler position with the knees slightly bent to reduce tension on the abdomen, keeps the patient nothing by mouth, stays with the patient, monitors for shock, and ensures the surgeon is notified immediately. Option 1 is never done and can cause serious injury and contamination. Option 3 damages tissue and does not keep it moist. Option 4 worsens the separation and delays emergency care.