Gastrointestinal Question #8
While the nurse is assisting a client to eat following abdominal surgery, the client begins to cough forcefully. The nurse observes intestinal evisceration. What is the first action the nurse should perform?
- Document the amount, color, drainage.
- Cover the intestines with sterile moist dressings.
- Place the client in low fowler’s position.
- Call the surgeon.
The low fowler’s position will take stress off the abdominal wound and will help minimize further extrusion of the intestines. Option A is incorrect since the nurse should not take time to document without intervening for the client. Option B may seem like the answer, but is incorrect since the position change must be made first, then the nurse may cover the intestines with sterile moist dressings. While option D is also correct action, it is not the first action since the client’s needs must be met first.