Which is the best initial action for the nurse to take?
An obese, malnourished client has undergone abdominal surgery. While ambulating on the fourth postoperative day, she complains to the nurse that her dressing is saturated with drainage. Before this activity, the dressing was dry and intact.
A. Splint the abdomen with a pillow and call the surgeon. B. Apply an abdominal binder. C. Reinforce the existing dressing with another dressing. D. Lift the dressing to assess the wound.
Lift the dressing to assess the wound.-rationale: the client probably has a wound evisceration or dehiscence. the first step is to assess the wound; then the nurse can implement appropriate measures. splinting the abdomen, applying an abdominal binder, or reinforcing the existing dressing would delay treatment.client needs category: physiological integrityclient needs subcategory: reduction of risk potentialcognitive level: applicationreference: taylor, c., et al. fundamentals of nursing: the art and science of nursing care, 6th ed. philadelphia: lippincott williams & wilkins, 2008, p. 1193.