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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is choice d. “Have you had small liquid stools?”

Choice A rationale:

While knowing the types of foods the client has been eating can provide insight into dietary habits that may contribute to constipation, it is not the most direct question to identify a fecal impaction.

Choice B rationale:

Asking about the use of stool softeners or laxatives is relevant to understanding the client’s bowel management, but it does not directly indicate the presence of a fecal impaction.

Choice C rationale:

Passing gas can indicate that there is some bowel movement, but it does not confirm or rule out a fecal impaction.

Choice D rationale:

Small liquid stools can be a sign of fecal impaction, as liquid stool may leak around the impacted mass. This makes it the most important question to ask when suspecting a fecal impaction.

A. "I will wait 15 minutes after drinking coffee to measure my blood pressure." B. "I will measure my blood pressure while my arm is elevated above my heart." C. "I should remove constrictive clothing prior to measuring my blood pressure." D. "I should measure my blood pressure immediately after eating breakfast.”

Correct Answer is C

Explanation

The correct answer is choice C: "I should remove constrictive clothing prior to measuring my blood pressure."

Choice A rationale:

"I will wait 15 minutes after drinking coffee to measure my blood pressure." Caffeine intake can temporarily elevate blood pressure, so waiting 15 minutes after drinking coffee is a good practice. However, this is not the most relevant instruction to ensure accurate blood pressure measurement.

Choice B rationale:

"I will measure my blood pressure while my arm is elevated above my heart." Measuring blood pressure with the arm elevated above the heart can result in artificially low readings. The arm should be supported at heart level for accurate results. Therefore, this statement is incorrect.

Choice C rationale:

"I should remove constrictive clothing prior to measuring my blood pressure." This is the correct choice. Constrictive clothing can impact blood flow and give inaccurate readings. Removing tight clothing ensures the blood pressure cuff can be appropriately placed and that the measurements are reliable.

Choice D rationale:

"I should measure my blood pressure immediately after eating breakfast." Blood pressure can be affected by food intake, so it's recommended to wait at least 30 minutes after eating before measuring blood pressure. This choice is not accurate as immediate post-breakfast measurements may not provide accurate results.

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A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client and is concerned that the client might have a fecal impaction. Which of the following is the most important question for the nurse to ask?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is C

Explanation

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