Place the actions in order after a postoperative client coughs and abdominal organs protrude through the incision.
Ordered Response
Choose your responses, then check the answer.
Explanation
Remain with the client and summon help. Reduce strain on the incision, then protect exposed tissue from drying and trauma with warm sterile saline-moistened dressings. Notify the surgeon and emergency team for urgent operative repair. Keep the client NPO, support circulation, and monitor for deterioration while preparing for surgery. Never push organs back into the abdomen.
Correct sequence Stay and call → reduce tension → protect exposed tissue → urgent surgical escalation → NPO support and monitoring.
Why this is correct Evisceration exposes abdominal contents to drying, contamination, and injury and reflects fascial failure requiring emergency surgical management.
NCLEX decision rule Moist sterile protection, not reinsertion; surgical escalation, not routine dressing change.
References
1NCBI Nursing Skills: Wound Care
2NCBI: Fascial Dehiscence
Abdominal eviscerationThe client is awake, frightened, and hemodynamically stable at discovery. Emergency surgical supplies and sterile saline are available.
Evisceration — Protrusion of abdominal organs through a disrupted surgical incision.
Dehiscence — Partial or complete separation of previously approximated wound layers.
Fascial Closure — Surgical approximation of the strong connective-tissue layer that maintains abdominal wall integrity.