A nurse is caring for a client who has an evisceration of an abdominal incision. Which of the following actions should the nurse take first?

Wound evisceration is a rare but catastrophic surgical complication where a surgical incision opens (dehiscence) and the internal organs, typically the small intestine, protrude through the opening. This is a medical emergency that requires immediate nursing intervention to prevent the bowel from drying out, becoming necrotic, or suffering from impaired blood supply. The nurse must act quickly to protect the exposed tissue while simultaneously preparing the client for emergency surgical repair to re-insert the organs and close the defect. A. Covering the protrusion with a dressing soaked in 0.9% sodium chloride is the priority action. When internal organs are exposed to the air, they begin to dry out (desiccate) and become cold, which can lead to tissue necrosis and severe infection. Using a sterile, saline-soaked dressing keeps the tissue moist and protected from the external environment. This sterile-moist barrier is the most critical immediate step to maintain the viability of the eviscerated bowel. B. Raising the head of the bed to 20° is a helpful supportive measure to reduce intra-abdominal pressure and tension on the wound edg es. However, it is not the first priority compared to the immediate physical protection of the exposed viscera. While positioning can prevent further protrusion, it does not address the immediate risk of the exposed tissue drying out. C. Obtaining the client's vital signs every 5 minutes is an essential monitoring task to detect early signs of shock or systemic distress, but it is not the first action to be taken. In an emergency ABCs or safety-first scenario, the nurse must first stabilize the emergency site. Once the eviscerated tissue is covered and protected, the nurse should then delegate or perform the assessment of vital signs to monitor for hemodynamic stability. D. Preparing the client for surgery is a necessary part of the overall management plan, as an evisceration always requires surgical closure. This involves tasks such as making the client NPO, ensuring consent is ready, and starting an IV line if one is not present. However, these steps follow the immediate stabilization of the wound. The nurse must first ensure the protruding organs are not damaged by exposure before shifting focus to the logistical preparations.