A nurse is assessing a client who is postoperative following abdominal surgery. The client states, "I feel like my incision ripped open. "The nurse notes dehiscence of the incision. Which of the following actions should the nurse take?

A. Extend the client's legs above heart level: Elevating the legs may improve venous return but does not reduce tension on the abdominal incision or help prevent further dehiscence. It does not address the immediate concern of protecting the surgical site. B. Place the client in a low-fowler's position: Positioning the client in a low-Fowler’s position (head of bed at 15–30 degrees) helps reduce intra-abdominal pressure on the incision and prevents further separation of the wound edges. This positioning supports comfort and minimizes strain while preparing for dressing application or further intervention. C. Instruct the client to perform the Valsalva maneuver: Asking the client to strain or hold their breath increases intra-abdominal pressure, which can worsen dehiscence and increase the risk of evisceration. This action is unsafe and should be avoided. D. Apply a dry gauze dressing to the incision: Applying a dry dressing alone does not protect the exposed tissue and may increase the risk of infection if evisceration occurs. The initial priority is to reduce tension on the wound by positioning before implementing sterile protective measures, such as a saline-moistened sterile dressing if necessary.