Author Question: During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What ... (Read 24 times)

Kikoku · **on:** Jul 23, 2018

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9 sodium chloride solution?

A) Document the assessments and intervention.
B) Reinforce the dressing with additional layers.
C) Administer pain medications intramuscularly.
D) Notify the physician and prepare for surgery.

Question 2

The plan of care for a postoperative client specifies that sterile 0.9 sodium chloride solution be used to clean the wound. What should the nurse do after reading this information?

A) Question the physician about the accuracy of this agent.
B) Refuse to use 0.9 normal saline on a wound.
C) Document the rationale for not changing the dressing.
D) Continue with the dressing change as planned.

Dinolord · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Ans: D
Protrusion of the intestines through an opened wound indicates evisceration. After covering the wound with towels soaked in sterile normal saline, the nurse should immediately notify the physician. Immediate surgical repair is required.

Answer to Question 2

Ans: D
Although various antiseptic cleaning agents could be used to clean a wound, sterile 0.9 normal saline is usually the agent of choice. Other agents may be caustic to skin and tissues.