A patient who is recovering from an abdominal wound tries to sit up in bed. The nurse notices a popping sound and checks the abdominal incision, which is leaking a significant amount of serosanguineous drainage. Which intervention of the nurse is most appropriate?

 

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Correct

- Cover the incision with a sterile dressing

- Check the patients blood pressure

- Elevate the patients legs

- Administer 100 percent oxygen by facial mask

Rationale

The patient has most likely suffered wound dehiscence, which occurs when a wound breaks open. In this case, dehiscence was indicated by a popping sound, most likely of sutures breaking, and increased drainage. The nurse's first action is to protect the wound by covering it with a sterile dressing and then calling for help.

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