A nurse is creating a plan care for a client who requires suture removal. Which of the following actions should the nurse plan to take?
Pull the visible part of the suture through the underlying tissue.
Cleanse the wound with sterile water prior to removing the sutures.
Cut the sutures as close to the skin as possible.
Remove the sutures in a consecutive order.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Determine how the client views the concept of a family: Understanding the client’s personal definition of family helps the nurse identify who the client considers significant for support and involvement in care planning, ensuring a patient-centered approach.
B. Identify how culture influences family functioning: Cultural influences are important in understanding family dynamics, but assessing the client’s perception of family comes first. Culture shapes interactions, but only after the nurse knows who the family members are from the client’s perspective.
C. Determine if the client has an external support system: Knowing about external supports is valuable, but this information is secondary to identifying the client’s family structure and relationships. Support systems can be assessed once the family context is clear.
D. Identify how the family deals with unexpected health changes: Assessing coping strategies is necessary for planning interventions, but it should occur after the nurse has first established who comprises the client’s family and understands their roles.
Correct Answer is C
Explanation
A. Tilt the client's head away from the side receiving the drops: The client’s head should be tilted slightly back and toward the side receiving the drops, not away. Tilting away may cause the medication to run out instead of entering the conjunctival sac.
B. Instill the drops directly onto the cornea of the eye receiving the drops: The cornea is highly sensitive, and placing drops directly on it can cause pain, reflex blinking, or injury. Drops should be placed into the conjunctival sac to ensure comfort and proper absorption.
C. Rest the dominant hand on the client's forehead while instilling the drops: Resting the hand on the forehead stabilizes the dropper, preventing accidental injury if the client moves suddenly. This provides safety and accuracy when administering the medication.
D. Hold the medication dropper 0.5 cm (0.2 in) above the conjunctival sac: The dropper should be held about 1–2 cm above the sac to avoid touching the eye. Holding it too close increases the risk of contamination or accidental contact with the eye surface.
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