腹部手術後病人發生傷口裂開且可見腹腔內臟器，護理師應採取哪些措施？（選所有適合的）
A client is recovering from abdominal surgery. The nurse notes the wound edges are separating and abdominal contents are visible. What actions should the nurse perform? (Select all that apply.)
- ACover the protrusion with a sterile saline-soaked dressing✓ 正解以無菌生理食鹽水浸濕的紗布覆蓋突出的臟器
- BPlace the client in a low-Fowler’s position with knees flexed✓ 正解讓病人採取膝蓋彎曲的低福勒氏體位
- CGently push the organs back into the abdominal cavity輕輕將臟器推回腹腔
- DMonitor the client for signs of shock✓ 正解監測病人是否有休克跡象
- EProvide the client with clear liquids to maintain hydration提供病人清流質以維持水分
傷口裂開（Evisceration）是外科緊急情況。正確處置為：覆蓋濕潤敷料以防臟器乾燥、維持屈膝低坐位以減輕腹部壓力、密切監測休克徵象。嚴禁推回臟器（增加感染與損傷）及進食（為後續緊急開刀做準備）。
Wound evisceration is a surgical emergency. Correct management consists of covering the protruding organs with a moist sterile dressing to prevent desiccation, maintaining the client in a low-Fowler's position with knees flexed to reduce abdominal tension, and closely monitoring for signs of shock. It is strictly prohibited to push the organs back into the cavity (which increases the risk of infection and injury) or to allow oral intake (the client must remain NPO in preparation for emergency surgery).
美國護理師直接採取緊急 protocol；台灣護理師在採取措施同時通常會同步啟動緊急醫療應變小組。