What is the immediate nursing action when a client reports a feeling of "something give way" in an abdominal incision?

What is the immediate nursing action when a client reports a feeling of "something give way" in an abdominal incision?

• A. Covers the abdominal wound with a sterile dressing moistened with sterile saline solution.
• B. Administers pain medication for the discomfort.
• C. Places the client in a supine position for assessment.
• D. Contacts the physician for further guidance.

Answer: (A)

When a client reports a feeling of "something give way" in an abdominal incision, the immediate nursing action is to cover the abdominal wound with a sterile dressing moistened with sterile saline solution. This action is crucial because it helps to protect the incision site from infection and further injury, particularly in the case where there may be dehiscence (the reopening of the surgical wound). Applying a sterile dressing can also help to manage any exudate and reduce the risk of contamination from the environment. The other actions, while important in different contexts, do not address the immediate concern of protecting the surgical site. Administering pain medication would be a supportive measure but does not address the potential complication that has arisen from the client's report. Placing the client in a supine position may be appropriate for assessment but does not provide immediate care for the open or compromised wound. Contacting the physician for further guidance is necessary, but the priority should be to secure the wound first to prevent complications while awaiting further instructions.

When a client reports a feeling of "something give way" in an abdominal incision, the immediate nursing action is to cover the abdominal wound with a sterile dressing moistened with sterile saline solution. This action is crucial because it helps to protect the incision site from infection and further injury, particularly in the case where there may be dehiscence (the reopening of the surgical wound). Applying a sterile dressing can also help to manage any exudate and reduce the risk of contamination from the environment.

The other actions, while important in different contexts, do not address the immediate concern of protecting the surgical site. Administering pain medication would be a supportive measure but does not address the potential complication that has arisen from the client's report. Placing the client in a supine position may be appropriate for assessment but does not provide immediate care for the open or compromised wound. Contacting the physician for further guidance is necessary, but the priority should be to secure the wound first to prevent complications while awaiting further instructions.