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    Hesi rn pediatric and women health (wgu) proctored exam

    A nurse is caring for a client who is 1-day postoperative following abdominal surgery. On assessment, the nurse notices evisceration from the surgical site. Which of the following actions should the nurse take?

    Explanation & Rationale

    Choice A reason: Applying a saturated abdominal dressing (with sterile normal saline) is correct. Moist dressings prevent the exposed abdominal organs from drying out and reduce the risk of tissue necrosis. This is the immediate priority intervention until surgical repair can be performed. Choice B reason: Cleansing the site with hydrogen peroxide is inappropriate because it can damage exposed tissues and increase the risk of infection. Hydrogen peroxide is not used for internal organ exposure. Choice C reason: Covering the site with dry, sterile gauze is incorrect because dry gauze can adhere to the viscera, causing tissue damage when removed. Moist dressings are required to protect the organs. Choice D reason: Reinserting protruding viscera is unsafe and contraindicated. Attempting to push organs back into the abdominal cavity can cause trauma, infection, and further complications. The nurse should protect the viscera and notify the surgical team immediately.

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