A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first?

Choice C rationale Positioning the client in a supine position with the knees flexed is the initial action to reduce intra-abdominal pressure. This specific posture relaxes the abdominal wall muscles and helps prevent further protrusion of the viscera through the surgical incision. By minimizing the tension on the wound site, the nurse provides a mechanical advantage that may limit the extent of the evisceration. This step is a critical component of emergency bedside management before applying protective dressings or preparing for surgery. Choice A rationale Covering the protruding bowel with a moist, sterile saline dressing is an essential intervention to prevent the tissue from drying out and to maintain sterility. Dehydration of the intestinal mucosa can lead to necrosis and permanent tissue damage, complicating the surgical repair. While this is a high-priority action, the immediate physical positioning of the patient to stabilize the site and reduce pressure often precedes the retrieval and application of sterile supplies. Both actions must occur rapidly to ensure the best outcome. Choice B rationale Informing the client about the necessity of returning to the operating room is part of providing emotional support and necessary information during a crisis. However, this communication does not address the immediate physical threat posed by the evisceration. The nurse's primary focus must be on physical stabilization and protecting the exposed organs. Providing explanations is important for informed consent and anxiety reduction, but it should happen concurrently with or immediately following the physical interventions required to save the tissue. Choice D rationale Checking vital signs is necessary to assess the client for signs of shock, such as a drop in blood pressure or an increase in heart rate. Significant surgical complications like evisceration can cause severe stress and physiological instability. However, the physical management of the wound and the prevention of further organ protrusion are the most immediate needs. Once the patient is positioned and the wound is covered, a full set of vitals provides a baseline to monitor for systemic decompensation while awaiting the surgeon.