Patient Data Which should the nurse immediately do? Select all that apply.

A. Notify the surgeon: The client is experiencing wound evisceration, a surgical emergency. Immediate notification of the surgeon is essential to prepare for urgent surgical repair and prevent further tissue damage or infection. B. Assist the client to cough and deep breathe: This increases intra-abdominal pressure and could worsen the evisceration. It is contraindicated in clients with open abdominal wounds and protruding organs. C. Encourage the client to drink fluids: Oral intake is not appropriate when surgery is likely imminent. The client should remain NPO to reduce aspiration risk during anesthesia for emergent wound closure. D. Place the client in low-Fowler’s with knees raised: This position helps decrease tension on the abdominal wall and limits further protrusion of abdominal contents. It also promotes comfort while reducing strain on the wound. E. Cover the wound with moistened sterile gauze: Covering the exposed intestines with sterile saline-moistened gauze protects tissue from drying, contamination, and infection until surgical repair can occur. F. Hold pressure on the dressing: Applying pressure to eviscerated organs can cause trauma and worsen the injury. This action is inappropriate and unsafe in cases of abdominal wound dehiscence with evisceration. G. Start a peripheral IV (PIV): IV access is necessary to administer fluids, medications, and prepare for possible surgery. Establishing a reliable IV line is a priority in managing surgical emergencies like evisceration.