ATI Nur 231 Fundamentals Exam | Nurselytic

Correct Answer: B

Rationale: The correct immediate nursing action for a patient experiencing wound dehiscence is to apply a sterile saline dressing and notify the surgeon immediately (
Choice
B). This is crucial because wound dehiscence can lead to serious complications such as infection and further tissue damage. Applying a sterile dressing helps protect the wound from contamination, while notifying the surgeon promptly ensures timely intervention to address the issue surgically if needed.

In contrast, instructing the patient to cough and deep breathe (
Choice
A) is important for preventing respiratory complications post-operatively, but it is not the most appropriate action for wound dehiscence. Increasing oral fluid intake (
Choice
C) may be beneficial for overall healing, but it does not address the immediate risk of wound dehiscence. Applying pressure to the wound (
Choice
D) can cause further damage and is not recommended in this situation.

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