Wound Evisceration

A nurse is caring for 4 clients who are 4 days postop following abdominal surgery. The nurse should further assess which of the following clients for wound evisceration?

A client who reports feeling his incision separate when he sneezed The nurse should assess this client for wound dehiscence or evisceration. A wound evisceration can occur 4 to 5 days postoperatively following an increase in strain on the incision, such as from forceful coughing, sneezing, or vomiting. Client's often report feeling something has "popped" or opened in the wound.

A nurse is assessing a client who is postop following abdominal surgery. The nurse should identify that which of the following findings increases the client's risk for wound evisceration?

The client is morbidly obese. A client who is morbidly obese has an increased risk for wound dehiscence and evisceration due to excessive strain to the suture line. The nurse should instruct the client to support the incision when moving to reduce the risk for evisceration.

A nurse is assessing a client who is postop following abdominal surgery and discovers bowel protruding from client's incision. Which of the following actions should the nurse take first?

Contact the rapid response team. The greatest risk to this client is compromised blood supply to the bowel resulting in necrosis; therefore, the first action the nurse should take is to contact the rapid response team for immediately for assistance.

A nurse is assessing a client who is postop following abdominal surgery and discovers the client has bowel protruding from the incision. Which of the following actions should the nurse take?

Cover the wound with a nonadherent dressing The nurse should cover the wound with a nonadherent dressing moistened with warm sterile normal saline to protect the wound from infection and further injury.

A nurse is teaching a client who is postop following abdominal surgery. Which of the following instructions should the nurse to include to reduce risk for wound evisceration?

"Support your abdomen with a pillow when coughing." The nurse should instruct the client to support his abdomen with a pillow when coughing to provide support to the incision and reduce the risk for wound evisceration.