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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Stage 3 NREM (deep sleep) is characterized by difficulty awakening, as the body is in a restorative state with slow brain waves (delta waves). This makes it hard to rouse the patient, aligning with the physiological features of deep sleep, making this the correct finding.

Choice B reason: Awakening easily is typical of stage 1 or 2 NREM, not stage 3, where deep sleep makes arousal difficult. This finding is inconsistent with the slow-wave, restorative nature of stage 3 NREM, making it incorrect.

Choice C reason: Rapid eye movement occurs in REM sleep, not stage 3 NREM, which is a non-REM, slow-wave sleep phase without eye movement. This finding is specific to REM, making it incorrect for stage 3 NREM assessment.

Choice D reason: Elevated vital signs are not typical of stage 3 NREM, where the body is relaxed, with decreased heart rate and respiration. Elevated vital signs may occur in REM or wakefulness, making this an incorrect finding for deep sleep.

A. A patient who is recovering from a right total hip surgery B. A patient who has been admitted for stabilization of heart problems C. A patient who has been admitted with dehydration D. A patient who is in observation for chest pain

Correct Answer is A

Explanation

Choice A reason: Hip surgery involves invasive procedures, increasing infection risk due to surgical wounds, immobility, and potential hardware. This patient faces higher risk than others, making it the correct choice.

Choice B reason: Heart problem stabilization may involve catheters, but surgical wounds pose a greater infection risk. Cardiac patients are less prone to immediate infection unless invasive devices are present, making this less likely.

Choice C reason: Dehydration weakens immunity but is less directly linked to infection than surgical wounds. Hydration correction reduces risk, making this patient less at risk than the surgical patient.

Choice D reason: Chest pain observation typically involves non-invasive monitoring, with lower infection risk than surgery. Without invasive procedures, this patient is less susceptible, making this incorrect.

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A nurse is removing staples from a client’s surgical incision. Which of the following will ensure safe removal? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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