Examkin

Question

Difficulty: MediumPhysiological Adaptation

A client who is three days postoperative following an abdominal laparotomy suddenly reports a "popping" sensation after a forceful cough. The practical nurse examines the surgical site and observes that the incision has separated and a loop of bowel is protruding. In which order should the nurse perform the following actions? (Arrange from first action to last)

  1. 1Stay with the client and call for immediate emergency assistance.
  2. 2Place the client in a low Fowler's position with the knees flexed.
  3. 3Cover the protruding tissue with sterile, saline-moistened dressings.
  4. 4Obtain the client's vital signs to monitor for indications of shock.
  5. 5Document the appearance of the evisceration and the interventions provided.

Answer

The correct sequence is to first stay with the client and call for help, then position them in low Fowler's with flexed knees, followed by covering the wound with sterile saline-moistened dressings, assessing vital signs, and finally documenting the event.
The correct sequence logically follows the principles of emergency nursing care: secure assistance without abandoning the client (call for help), immediately stabilize the mechanical threat using positioning (low Fowler's with bent knees), protect the compromised biological tissue (sterile moist dressings), monitor for systemic decompensation (vital signs), and conclude with accurate administrative recording (documentation).

Step-by-Step Solution

1
Recognize the medical emergency (wound evisceration).
Immediate identification that the client's internal organs are exposed and vulnerable to injury and infection.
Rapid recognition dictates that the client must not be left alone, necessitating a call for help as the absolute first action.
2
Implement immediate mechanical protection without requiring supplies.
The client is placed in low Fowler's position with knees flexed.
This specific position minimizes tension on the abdominal musculature, halting the further evisceration of the bowel.
3
Apply localized tissue protection once supplies are brought to the bedside.
The eviscerated bowel is covered with sterile, saline-moistened dressings.
Moist sterile dressings preserve tissue viability, prevent cellular necrosis, and form a barrier against environmental pathogens.
4
Assess systemic physiological adaptation and stability.
Vital signs are measured to establish a baseline during the acute event.
Monitoring blood pressure and pulse identifies the onset of hypovolemic shock or severe physiological distress.
5
Complete legal and medical record requirements.
The emergency event, interventions, and client status are documented.
Documentation must reflect chronological facts but is prioritized last to ensure direct client care is not delayed.

Key Concept

Prioritization of Nursing Interventions for Surgical Evisceration
Rate this question

Topics

Physiological Adaptation

More questions from this topic