Dehiscence and Evisceration (10 Questions)

1. Ms. Machin, a 34-year-old patient, had a cesarean section five days ago. During a routine follow-up, you notice that her surgical dressing has been removed, and there is a small wound (separation of the surgical wound) at the incision site. She reports mild discomfort but no signs of infection (e.g., redness, heat, or purulent discharge). Ms. Machin is concerned because she needs to care for her two young children at home.

Question:
As the nurse, what should you do as a priority? *

Apply Steri-Strips to approximate the wound edges and reinforce with a clean dressing.

Advise Ms. Machin to avoid lifting her children and provide instructions on activity modification.

Notify the doctor immediately for further instructions.

Clean the wound with an antiseptic solution and leave it open to air.

2. Mr. Delacruz, a 58-year-old patient, is recovering on the surgical floor following an open abdominal procedure performed five days ago. While assisting him during a coughing episode, he suddenly becomes alarmed and states, “Something just gave way in my belly.” You quickly inspect the abdominal incision and observe a separation in the wound with visible tissue protruding through the opening. Mr. Delacruz appears anxious but remains hemodynamically stable.

Question:
What is your priority intervention? *

Reassure the patient and check vital signs.

Cover the wound with sterile saline-moistened gauze and notify the surgeon.

Instruct the patient to lie flat and call for help.

Apply pressure to the wound to stop any bleeding.

3. Mr. Lewis, a 62-year-old client, is recovering from thoracic surgery performed three days ago. During your morning rounds, he reports experiencing pain at the incision site whenever he coughs or takes a deep breath. He appears apprehensive and states that the pain discourages him from performing breathing exercises. His vital signs are stable, and the surgical dressing appears dry and intact. He asks if the pain is normal and what he can do to relieve it.

Question:
Which action would the nurse take? *

Instruct the client to splint the wound with a pillow when coughing

Place the client in the supine position and inspect the site of the incision

Assess the intensity of the pain and administer the prescribed analgesic

Notify the health care provider immediately

4. Ms. Rivera, a 47-year-old client, is in the postoperative unit after undergoing abdominal surgery two days ago. She is wearing an abdominal binder to provide support to her incision site, reduce pain during movement, and minimize the risk of wound complications. The physician has prescribed a dressing change to the surgical site. You are preparing to perform the procedure while ensuring her comfort and maintaining wound integrity.

Question:
Which intervention should the nurse include in relation to the prescribed dressing change? *

Remove the binder to change the abdominal dressing as prescribed and reapply it afterward

Slide the new dressing under the binder to avoid removing it and causing discomfort

Keep the binder in place and change only the outermost layer of the dressing

Loosen the binder slightly without removing it to access the incision site

5. Mr. Thompson, a 55-year-old patient, has just returned from surgery after undergoing an abdominal procedure. During the post-op assessment, the nurse receives a new order from the health care provider to apply an abdominal binder around the patient’s midsection. The surgical dressing is dry and intact, and the patient is alert and reports mild discomfort at the incision site when moving or coughing.

Question:
What is the most likely indication for this intervention? *

Promote blood flow to the incision site

Support the diaphragm and reduce pain when breathing

Reduce stress on the abdominal incision

Prevent the need for frequent dressing changes

6. Mme. Thibault, 41 years old, is on postoperative day 5 after a C-section. She states her incision “feels wet.” You observe small separation, moderate serosanguinous drainage, but no purulent discharge, fever, or pain increase.

Question:
Which intervention should the nurse implement as a priority? *

Clean the area and apply Steri-Strips to approximate the edges

Assess for signs of infection and notify the provider

Apply an abdominal binder for support

Reinforce the dressing and monitor for progression

7. Mme. Rousseau, 72 years old, recently discharged after abdominal surgery, returns to the clinic because her incision “opened a little” when getting up from a chair. You see minimal separation with clean edges, no redness, and no fever.

Question:
What is the nurse’s priority action? *

Advise rest and limited movement until wound closes

Apply Steri-Strips and reinforce with a clean dressing

Leave the wound open to air for faster healing

Pack the wound with dry gauze

8. Mr. Bouchard, 58 years old, postoperative day 6 after prostatectomy, is worried because his incision has a small dehiscence. He reports normal temperature and no drainage increase. He is supposed to be discharged tomorrow.

Question:
Which nursing action takes priority? *

Provide teaching about activity restriction and wound care

Request a wound care consult

Leave the wound open to promote drying

Encourage him to resume activities as tolerated

9. Mme. Morin, 66 years old, postoperative day 5 following colon surgery with obesity and chronic cough, shows moderate dehiscence with tension on the edges. She reports feeling “pressure inside” when coughing.

Question:
What should the nurse do as a priority? *

Apply an abdominal binder for support

Encourage coughing and deep breathing

Leave the incision uncovered for observation

Apply firm pressure over the incision

10. Mme. Dion, 63 years old, is on postoperative day 3 following an open cholecystectomy. She has a history of uncontrolled diabetes, and her blood glucose this morning is 14.8 mmol/L. During assessment, you see mild redness around her incision, and she reports fatigue and poor appetite. No dehiscence is present yet.

Question:
Which factor places Mme. Dion at the highest risk for wound dehiscence? *

Her low level of appetite

Her elevated blood glucose levels

The redness around the incision

Her age alone