A nurse caring for a postoperative client removes the client's dressing and notes an area of dehiscence. Which of the following actions should the nurse take?

Rationale: A. Place the head of the client's bed flat with the client's legs extended: Positioning flat may increase tension on the abdominal incision, potentially worsening the dehiscence. A low Fowler’s position with knees slightly bent is preferred to reduce strain on the wound. B. Apply butterfly strips to approximate the wound edges: Forcing the wound edges together could trap bacteria inside and increase the risk of infection. Dehiscence requires moist protection, not forced closure at the bedside. C. Apply pressure directly to the wound for 15 min: Direct pressure is appropriate for active bleeding, not for dehiscence. Applying pressure could damage tissues further and does not address the need to protect exposed structures. D. Place a sterile, saline-soaked dressing on the wound: A moist sterile dressing protects the wound from contamination, prevents the tissues from drying, and reduces the risk of infection while awaiting further surgical evaluation.