A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take?
Lift the staple remover when squeezing the handle.
Avoid completely closing the handle after squeezing.
Expect the staples to bend at each outer side of the staple.
Remove the staple from the skin after both sides are visible.
The Correct Answer is D
The correct answer is: d. Remove the staple from the skin after both sides are visible.
Explanation: This statement is correct because the staple should be removed only when both sides are visible, ensuring that it has been fully lifted away from the skin. This helps minimize tissue damage and pain while preventing infection.
Choice A Rationale: Lifting the staple remover when squeezing the handle could potentially disrupt the proper angle required for effective staple removal. Staples are designed to be removed in a specific manner to minimize tissue trauma and discomfort to the patient. If the staple remover is lifted while squeezing the handle, it may cause uneven pressure on the staple legs, leading to improper removal. This could result in tissue damage, increased pain for the patient, and potentially leave parts of the staple embedded in the skin, increasing the risk of infection or delayed healing.
Choice B Rationale: Avoiding completely closing the handle after squeezing may not provide sufficient force to properly remove the staple from the skin. Staples are designed to be squeezed closed completely to ensure that they are securely grasped and removed from the incision site. Failing to fully close the handle after squeezing may result in inadequate removal of the staple, leaving parts of it behind in the skin. This can increase the risk of infection, tissue irritation, and delayed wound healing. Additionally, incomplete closure of the handle may lead to discomfort for the patient as the staple removal process may be prolonged or require additional attempts.
Choice C Rationale: Expecting the staples to bend at each outer side during removal is incorrect. Staples are designed to bend in the middle when properly removed from the skin. If the outer sides of the staple were expected to bend, it may indicate improper technique or the use of a faulty staple remover. Staples are intended to be removed smoothly without excessive bending or twisting to minimize trauma to the surrounding tissue and reduce the risk of complications such as infection or delayed wound healing. Anticipating bending at the outer sides could lead to unnecessary manipulation of the staple and increase the likelihood of tissue damage or incomplete removal.
Choice D (Correct Answer) Rationale: Removing the staple from the skin only after both sides are visible is the appropriate technique to ensure proper removal without causing unnecessary trauma or discomfort to the patient. When both sides of the staple are visible, it indicates that the staple has been adequately lifted away from the skin, reducing the risk of tissue damage or incomplete removal. This technique allows for a smooth and controlled extraction of the staple, minimizing pain and promoting optimal wound healing. By waiting until both sides are visible, the nurse can confirm that the staple has been fully disengaged from the tissue, reducing the likelihood of complications such as infection or skin irritation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choiceC. “You should cleanse your eye from the inner to the outer edge prior to putting in the drops.”
Choice A rationale:
Looking to the side when putting in eye drops is not recommended.The correct technique involves looking up to help the drop fall into the eye more easily.
Choice B rationale:
Putting drops directly in the center of the eyeball can cause discomfort and may not be effective.The drops should be placed in the lower eyelid pocket.
Choice C rationale:
Cleansing the eye from the inner to the outer edge helps remove any debris or discharge, reducing the risk of infection and ensuring the drops are effective.
Choice D rationale:
Pressing on the tear duct after putting in eye drops can help prevent the medication from draining away too quickly, ensuring better absorption.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Rinsing forearms with running water before applying soap is not a recommended step in the handwashing procedure. The primary step is to wet the hands, apply soap, and create a lather.
Choice B rationale:
Holding hands above elbow level while washing and rinsing is not a standard practice for handwashing. The hands should be washed thoroughly, and the focus is on scrubbing the hands, not their positioning.
Choice C rationale:
Generating a lather by rubbing hands together vigorously for 5 seconds is insufficient for effective handwashing. Proper handwashing involves rubbing hands together for at least 20 seconds to ensure thorough cleaning.
Choice D rationale:
The correct answer. After washing and drying hands, turning off the faucet with a clean paper towel is recommended to avoid recontaminating the clean hands. Touching the faucet directly with clean hands could potentially transfer pathogens back onto the hands.
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