Fundamentals Question #35
A client recovering from an exploratory laparotomy for gastrointestinal cancer has evisceration and protrusion of abdominal organs. What intervention should the nurse do first?
- Notify the admitting health care provider immediately
- Palpate for abdominal tenderness in the area of evisceration
- Cover protruding intestine with saline soaked sterile gauze
- Assess for hypoactive bowel sounds and check blood pressure
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 client 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 client receives an intervention to protect the eviscerated organs..