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. Release of personal belongings form.
Choice A rationale:
Completion of an incident report is not typically part of postmortem care documentation unless there was an unusual or unexpected event surrounding the death.
Choice B rationale:
While the name of the nurse certifying the client’s death is important, it is usually documented separately in the death certificate or other official records, not necessarily in the postmortem care documentation.
Choice C rationale:
The release of personal belongings form is crucial as it ensures that the client’s belongings are properly accounted for and handed over to the appropriate person, providing a clear record of what was released and to whom.
Choice D rationale:
Documenting one client identifier at the time of death is important, but it is not specific to postmortem care documentation. Identifiers are generally used throughout the client’s medical record to ensure accuracy and consistency.
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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