A client’s abdominal incision eviscerates. The nurse should first:
1. Take the client’s vital signs and call the physician.
2. Lower the client’s head and elevate the feet.
3. Cover the incision with a dressing moistened with sterile normal saline solution.
4. Start an emergency infusion of IV fluids.
When an incision eviscerates, it is a medical emergency. The nurse’s first response is to apply a sterile dressing that has been moistened with sterile normal saline solution.
The client should also be placed in semi-Fowler’s position to release any tension on the abdominal area. Vital signs should be taken, and an IV line may be started for emergency treatment; however, the first action is to protect the wound and abdominal contents.
CN: Reduction of risk potential; CL: Synthesize