A nurse is removing staples from a client’s surgical incision. Which of the following will ensure safe removal? (Select all that apply)
Assure the client there will be no discomfort during the procedure
Clean the surgical site
Lift the staple remover when squeezing the handle
Verify the prescription for staple removal
Examine the incision
Correct Answer : B,D,E
Choice A reason: Assuring no discomfort is misleading, as staple removal may cause mild pain. Providing accurate expectations ensures trust and cooperation, but this does not contribute to safe removal, making it incorrect.
Choice B reason: Cleaning the surgical site removes bacteria, reducing infection risk during staple removal. Aseptic technique is essential for safety, preventing wound contamination, making this a correct intervention for safe procedure execution.
Choice C reason: Lifting the staple remover when squeezing the handle is incorrect, as it may tear tissue. The remover should be pressed down to extract staples gently, making this an unsafe action and incorrect.
Choice D reason: Verifying the prescription ensures the procedure is authorized and timely, preventing premature removal that could cause dehiscence. This safety step confirms medical appropriateness, making it a correct intervention.
Choice E reason: Examining the incision assesses healing and identifies complications like infection before removal. This ensures staples are removed only if the wound is stable, making it a correct safety measure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Applying the patch to the same site daily risks skin irritation and reduced absorption. Rotating sites (e.g., chest, arms) ensures efficacy, making this an incorrect instruction.
Choice B reason: Removing the nitroglycerin patch at night provides a nitrate-free period, reducing tolerance and maintaining efficacy. This is standard practice, making it the correct instruction for the client.
Choice C reason: Cutting the patch disrupts the controlled-release mechanism, causing unpredictable dosing and risks. Dizziness requires medical evaluation, not patch modification, making this incorrect and unsafe.
Choice D reason: Limiting application to the upper arm restricts options. Patches can be applied to hairless areas like the chest or back, making this unnecessarily restrictive and incorrect.
Correct Answer is B
Explanation
Choice A reason: Storing unopened insulin in the freezer can degrade it. Refrigeration is correct, keeping insulin stable, making freezing incorrect for proper storage instructions.
Choice B reason: Rotating injection sites prevents lipodystrophy (tissue changes) by avoiding repeated trauma. This ensures consistent absorption, making it a critical instruction for insulin administration.
Choice C reason: Shaking insulin vials can damage proteins or create air bubbles, affecting efficacy. Gentle rolling is recommended for cloudy insulin, making this incorrect for proper handling.
Choice D reason: A 30-degree angle is too shallow for subcutaneous insulin; a 45–90-degree angle is standard. This incorrect technique may affect absorption, making it wrong.
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