# Place the actions in order after a postoperative client coughs and abdominal organs protrude through the incision.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=395474&lang=en  
> language: en  
> subject: Expected Actions/Outcomes  
> category: PPT

## Question

Place the actions in order after a postoperative client coughs and abdominal organs protrude through the incision.

Cover the exposed organs with sterile dressings moistened with warm sterile normal saline without attempting reinsertion

Notify the surgeon and rapid-response team urgently and prepare for emergency operative management

Stay with the client, call for assistance, and instruct the client not to cough, strain, or touch the protruding tissue

Keep the client NPO, maintain prescribed IV support, monitor vital signs and perfusion, and provide calm reassurance

Position the client supine with knees flexed and the head only slightly elevated if tolerated to reduce abdominal tension

## 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.

## In-depth explanation

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

## Clinical scenario

Abdominal evisceration
The client is awake, frightened, and hemodynamically stable at discovery. Emergency surgical supplies and sterile saline are available.

## Key concepts

- **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.

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