CJE 2 Fundamentals Practice Exam 2026 - Free CJE 2 Practice Questions and Study Guide

When a client reports that a wound has opened and staples are missing, the most immediate action the nurse should take is to cover the wound with a sterile, saline moistened dressing. This action helps protect the wound from further contamination, reduces the risk of infection, and maintains a moist environment that is conducive to healing. It is essential to ensure the wound is properly covered before taking additional steps, as this can help stabilize the situation and prevent complications.

Checking the client's vital signs is important but is not the first priority; it typically happens after addressing immediate concerns with the wound. Notifying the surgeon is also crucial, but it usually follows initial wound management. Documenting the incident is necessary for maintaining accurate medical records, but again, it should come after ensuring the wound is covered and safe. Therefore, the focus must first be on protecting the wound to ensure the client's safety and health.