A nurse is creating a plan care for a client who requires suture removal. Which of the following actions should the nurse plan to take?

Pull the visible part of the suture through the underlying tissue.

Cleanse the wound with sterile water prior to removing the sutures.

Cut the sutures as close to the skin as possible.

Remove the sutures in a consecutive order.

Answer and Explanation

The Correct Answer is C

A. Pull the visible part of the suture through the underlying tissue: Pulling the external portion of the suture through the tissue can introduce surface bacteria into the wound. This increases the risk of infection and should be avoided.

B. Cleanse the wound with sterile water prior to removing the sutures: Wounds are typically cleansed with sterile normal saline or an antiseptic solution, not sterile water. Normal saline is isotonic and safe for wound irrigation, whereas sterile water can damage tissue.

C. Cut the sutures as close to the skin as possible: Cutting close to the skin ensures only the buried portion of the suture is pulled through the tissue, reducing contamination and promoting proper healing.

D. Remove the sutures in a consecutive order: Sutures are usually removed every other one first to prevent wound dehiscence. Removing them consecutively can place stress on the wound edges and increase the risk of reopening.

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Correct Answer is A

Explanation

A. A client who has chronic back pain and a history of physical maltreatment: Therapeutic touch involves close physical proximity and intentional hand movements, which may trigger psychological distress or trauma responses in individuals with a history of maltreatment.

B. A client who has chronic joint discomfort and a history of mild dementia: Clients with mild dementia may still tolerate therapeutic touch well, as it can provide comfort and reduce agitation. With careful explanation and reassurance, this intervention can be beneficial.

C. A client who has chronic knee pain and a history of grand mal seizures: Therapeutic touch does not induce seizures, as it is a noninvasive energy-based practice. It does not increase seizure risk in clients with a seizure history.

D. A client who has chronic hip pain and a history of uterine cancer: Having a history of cancer is not a contraindication to therapeutic touch. This approach does not involve deep tissue manipulation and can be safely applied to provide comfort and pain relief.

A. Strong, bounding pulse B. Positive Chvostek's sign C. Hyperactive reflexes D. Decreased bowel sounds

Correct Answer is D

Explanation

A. Strong, bounding pulse: Hypokalemia causes weak, thready, or irregular pulses due to its effects on cardiac muscle excitability. A strong, bounding pulse is more characteristic of hypervolemia or other cardiovascular conditions.

B. Positive Chvostek's sign: A positive Chvostek’s sign is associated with hypocalcemia, not hypokalemia. It indicates neuromuscular excitability due to low calcium levels.

C. Hyperactive reflexes: Hypokalemia generally causes muscle weakness, fatigue, and diminished or hypoactive reflexes rather than hyperactive reflexes.

D. Decreased bowel sounds: Low potassium levels reduce smooth muscle excitability in the gastrointestinal tract, leading to decreased peristalsis and hypoactive bowel sounds, which is a common finding in hypokalemia.

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A nurse is creating a plan care for a client who requires suture removal. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is planning to use therapeutic touch for a group of selected clients who have chronic pain. The nurse should identify that the use of therapeutic touch is contraindicated for which of the following clients?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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