A post-operative client with an abdominal wound tries to reach over and take a book off the bedside table. He immediately screams and calls for the nurse. The nurse notices serosanguineous drainage coming from the incision on the abdomen. The first action the nurse should take is to
cover the incision with a sterile cloth or dressing.
lower the head of the bed to less than 10 degrees.
check the client’s vitals to assess for drop in blood pressure.
call and alert the surgeon.
Number 1 is correct.
The client likely inadvertently opened the sutures and caused the wound area to separate (wound dehiscence). The nurse’s first priority is to immediately cover and protect the open wound. Then the nurse should call for help and make any other necessary interventions.
