Editing Nursing Skills and Procedures – RN Practice Questions (section)

==Question 9==
On the fourth postoperative day, a client who is coughing suddenly reports that "something gave way." The nurse finds a loop of bowel protruding through the abdominal incision. Which actions should the nurse take? '''Select all that apply.'''
# Cover the protruding tissue with sterile gauze moistened with sterile normal saline.
# Gently replace the bowel into the abdominal cavity.
# Position the client in low Fowler position with the knees flexed.
# Keep the client NPO and monitor for signs of shock.
# Notify the surgeon immediately.
# Apply a dry occlusive pressure dressing and tape it securely.

'''Answer:''' 1, 3, 4, and 5 (A, C, D, E).

''Rationale:'' Evisceration is a surgical emergency. Moist sterile saline gauze prevents drying and necrosis of exposed viscera. Low Fowler with flexed knees reduces abdominal wall tension and further protrusion. The client is kept NPO in anticipation of operative repair and monitored for hypovolemic shock and peritonitis, and the surgeon is notified at once. Option 2 is never done, as it introduces contamination and can injure the bowel. Option 6 applies harmful pressure and a dry dressing desiccates the tissue.