A nurse is caring for a client who reports having insomnia due to increased stress. Which of the following actions should the nurse take first?

Rationale for correct choices:

• Pneumonia: The client has an elevated temperature, productive cough with thick white mucus, and mild crackles in the upper lobes. These findings, combined with recent immobility after surgery, indicate pulmonary infection risk.
• Respiratory findings: Crackles, cough, and sputum production directly support pneumonia as the complication most consistent with the client’s presentation.

Rationale for incorrect choices:

• Deep vein thrombosis: Although the client has nonpitting edema in the right leg, distal circulation is intact (pedal pulse 2+, capillary refill <2 seconds, foot warm). No calf pain, erythema, or unilateral swelling progression is reported.
• Urinary tract infection: The client voided a large amount of amber urine without dysuria, urgency, or suprapubic discomfort. No urinary abnormalities have been noted to suggest UTI.
• Nonpitting edema: This finding is expected locally after knee arthroplasty and does not indicate systemic infection.
• Elevated temperature: Fever alone is nonspecific and could be related to multiple postoperative risks; the respiratory findings provide more precise evidence for pneumonia.

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.