A nurse is caring for a client who is postoperative and has a PCA pump for pain management. The client states, "I have concerns about my pain pump." Which of the following responses should the nurse make?

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.

A. Use a reflex hammer: Clonus is assessed by using a reflex hammer to test deep tendon reflexes, typically at the ankle joint. Sustained rhythmic contractions following dorsiflexion of the foot confirm the presence of clonus, which often indicates upper motor neuron dysfunction.

B. Administer magnesium sulfate: Magnesium sulfate is a treatment used in conditions such as preeclampsia with severe features but is not a method of assessment. Medication administration would come after clonus has been identified, not during the diagnostic step.

C. Perform a Romberg test: The Romberg test assesses balance and proprioception, often used in neurological exams for cerebellar or sensory dysfunction. It does not evaluate for clonus, which specifically relates to abnormal reflex activity.

D. Test the gait for symmetry: Gait assessment provides information about coordination, strength, and balance. While it may reveal neurologic impairment, it does not directly test for clonus or identify the rhythmic contractions associated with it.