Nursing Acceleration Challenge Exam (NACE) PN-RN Practice Test

If a patient has a dehisced abdominal wound with partial evisceration, what should the nurse do immediately?

1. Leave the wound open to the air.

2. Cover the wound with sterile plastic wrap.

3. Cover the wound with dry, sterile dressings.

4. Cover the wound with sterile, saline-soaked dressings.

The correct answer is: Cover the wound with sterile, saline-soaked dressings.

In the case of a dehisced abdominal wound with partial evisceration, the immediate priority is to protect the exposed internal organs and prevent contamination, as well as to manage the patient's risk of infection and other complications. Covering the wound with sterile, saline-soaked dressings is the most appropriate intervention because the saline helps to maintain moisture in the tissue, support healing, and offer protection. It also reduces the risk of exposed visceral tissue drying out, which can lead to further complications such as necrosis. Using sterile dressings ensures that the area remains clean and helps prevent infection. Saline-soaked dressings specifically provide a moist environment that is conducive to healing tissue. This approach prioritizes the patient's safety while preparing them for further assessment and intervention by surgical teams, as surgical repair may be necessary for a wound of this nature.