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 B
Explanation
The correct answer is choice B: Empty the drainage bag when it is three-fourths full.
Choice A rationale:
Cleaning the perineal area at least once a day is important for maintaining hygiene, but it is not the most relevant action in this scenario. The focus here is on managing the urinary catheter and its drainage bag.
Choice B rationale:
Emptying the drainage bag when it is three-fourths full is the correct action. An indwelling urinary catheter requires regular drainage to prevent the risk of infection and blockages. Allowing the bag to become too full could lead to backflow and increase the likelihood of urinary tract infections.
Choice C rationale:
Flushing the catheter with sterile water daily is not typically part of routine catheter care. Catheter flushing might be done for specific medical reasons, but it is not a general guideline for indwelling catheters.
Choice D rationale:
Disconnecting the drainage bag when emptying and measuring urine is incorrect. Maintaining a closed system is crucial to prevent introducing bacteria into the urinary tract. Disconnecting the bag could increase the risk of infection.
Correct Answer is A
Explanation
The correct answer is choice A. Perform a bladder scan.
Choice A rationale:
Performing a bladder scan is the first action the nurse should take before proceeding with intermittent urinary catheterization. A bladder scan assesses the bladder's volume and determines if catheterization is necessary. It helps avoid unnecessary catheterizations, reduces the risk of infection, and promotes patient comfort.
Choice B rationale:
While cleansing the meatus and providing perineal care are important steps in preparing for urinary catheterization, they come after assessing the need for catheterization. Without knowing the bladder volume, these actions could be premature.
Choice C rationale:
Providing perineal care is important for maintaining hygiene and preventing infection, but it should be done after the decision for catheterization has been made based on the bladder scan results.
Choice D rationale:
Lubricating the catheter is a step that should be taken after the decision for catheterization is made and the need for catheterization is confirmed. It helps ease the insertion process and reduce discomfort for the patient.
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