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. Providing client information to another nurse at change of shift**.

Choice A rationale:

Sharing the client's prognosis with a family member without the client's consent violates the client's right to confidentiality. The nurse should only disclose information to family members if the client has provided permission or if it is necessary for the client's care.

Choice B rationale:

Discussing the client's status with a member of the spiritual support team may be appropriate if the client has consented to spiritual support and the nurse limits the discussion to information relevant to the spiritual care. However, disclosing the client's diagnosis or other sensitive information without the client's consent would still be a breach of confidentiality.

Choice C rationale:

Collaborating with a nurse from another unit about the client's care is appropriate if it is necessary for the client's treatment and if the discussion is limited to information relevant to the client's care. The nurse should ensure that the discussion takes place in a private setting and that no unauthorized individuals can overhear the conversation.

Choice D rationale:

Providing client information to another nurse at change of shift is necessary for the continuity of the client's care and is considered an appropriate disclosure within the healthcare team. The nurse should ensure that the discussion takes place in a private setting and that no unauthorized individuals can overhear the conversation.

A. Reduce intake of calcium-rich foods. B. Use sunscreen with skin protection factor (SPF) of 8. C. Take vitamin D supplements. D. Use a tanning bed 2 hr weekly.

Correct Answer is C

Explanation

The correct answer is Choice C: Take vitamin D supplements.

Choice A rationale:

Reducing intake of calcium-rich foods would not be a suitable recommendation. Calcium is essential for bone health, and a client with minimal sunlight exposure is at risk of vitamin D deficiency, which affects calcium absorption. Therefore, this choice would worsen the client's situation.

Choice B rationale:

Using sunscreen with an SPF of 8 is unlikely to provide adequate protection against the harmful effects of sunlight. Moreover, the client's issue is vitamin D deficiency due to minimal sunlight exposure, and using sunscreen would further hinder vitamin D synthesis.

Choice C rationale:

Taking vitamin D supplements is the most appropriate intervention. Vitamin D is synthesized in the skin upon exposure to sunlight, and since the client has minimal sunlight exposure, supplements are necessary to prevent vitamin D deficiency. This choice addresses the root cause of the issue.

Choice D rationale:

Using a tanning bed is not recommended for increasing vitamin D levels. Tanning beds emit ultraviolet (UV) radiation, which can increase the risk of skin cancer. Moreover, excessive UV exposure is not a safe or controlled method for addressing vitamin D deficiency.

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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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