HESI RN Med surg adult health proctored exam
A male client who had abdominal surgery 5 days ago and was hospitalized because of a wound infection tells the nurse that he feels like his insides just spilled out when he coughed. Which action should the nurse take first?
Explanation & Rationale
Choice A reason:The correct answer is a) because visualizing the abdominal incision will help the nurse assess for wound dehiscence or evisceration, which requires immediate intervention.Choice B reason: Notifying the healthcare provider is necessary but comes after assessing the wound.Choice C reason: Obtaining sterile towels soaked in saline is important if dehiscence or evisceration is confirmed but is not the first action.Choice D reason: Reassuring the client is important but does not address the immediate need to assess the wound.
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