Fundamentals Question #35

Question

A patient recovering from an exploratory laparotomy for gastrointestinal cancer has evisceration and protrusion of abdominal organs. What intervention should the nurse do first?

Answers

  1. Notify the admitting health care provider immediately
    • Rationale:
  2. Palpate for abdominal tenderness in the area of evisceration
    • Rationale:
  3. Cover protruding intestine with saline soaked sterile gauze
    • Rationale:
  4. Assess for hypoactive bowel sounds and check blood pressure
    • Rationale:

Overview

Explanation

The correct answer is C. Because the protruding organs are subject to trauma and drying, applying saline soaked sterile gauze provides protection until the surgeon can arrive. The nurse would provide care to the patient before notifying the health care provider. Pressure should never be applied to the site of evisceration. The abdomen should not be touched and blood pressure measurement can be done after the patient receives an intervention to protect the eviscerated organs..

Learning Outcomes

Test Taking Tip

Video Rationale