While inspecting the abdominal surgical wound, the nurse noticed wound evisceration. The immediate steps in nursing management include all, except?

Appeared in: SCTIMST Staff Nurse - 2015 (Set-B)

Explanation

The question asks to identify the action that is NOT a part of the immediate management of wound evisceration.
Applying a pressure dressing is strictly contraindicated because direct pressure on exposed viscera can impair blood flow, leading to tissue ischemia, damage, and necrosis.
The goal is to protect the organs, not to apply pressure or attempt to reduce them back into the abdominal cavity.
All other options represent correct and necessary interventions in this surgical emergency.

Option B: This is a correct and essential action. Wound evisceration is a surgical emergency that requires prompt repair in the operating room to prevent further complications.
Option C: This is a correct and critical action. The surgeon must be notified immediately to assess the patient and prepare for emergency surgery.
Option D: This is a correct action. Having the patient lie down is the first step. The optimal position is low-Fowler's with knees flexed to reduce tension on the abdominal muscles and incision site.

Clinical Relevance

Nursing practice connection: Knowing Management of Wound Evisceration helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Wound evisceration is a rare but life-threatening postoperative complication. Recognizing it and acting quickly can prevent severe infection, organ damage, and death.
Nurses must be able to differentiate between wound dehiscence (separation of wound edges) and evisceration (protrusion of organs) as the latter is a much more severe emergency.
What if? If the nurse observed wound dehiscence without evisceration, the immediate action would still be to cover the wound with a sterile dressing and notify the surgeon. However, the urgency is slightly less critical than with organ protrusion, though it still requires prompt attention to prevent progression to evisceration.

How to Approach the Question

First, identify the keywords in the question: "wound evisceration," "immediate steps," and the negative lead-in "except."
The word "except" means you are looking for the action that is incorrect or contraindicated.
Recall the standard nursing protocol for managing wound evisceration. This is a surgical emergency.
Evaluate each option against the correct protocol:
A) Provide pressure dressings: Is applying pressure to exposed organs safe? No, it can cause damage.
B) Prepare for wound closure: Is surgery needed? Yes, it's an emergency.

Concept Tested & Keywords

Concept Tested: Management of Wound Evisceration
Stem keywords: abdominal surgical wound, wound evisceration, immediate steps, nursing management
Lead-in keywords: except
Negative lead-in flag: except

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E6 Nursing Brunner Adult Health 3SA Vol 1 Part 1 p. 126-128

E6 Nursing Fundamentals Potter Perry 12e Part 6 p. 124-126

Practise the full SCTIMST Staff Nurse - 2015 (Set-B)

Attempt every question from this paper in a timed mock, then review the full solution for each one.