The nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding should the nurse expect?

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.

Choice A reason: Blood pressure of 148/92 mmHg indicates hypertension, not directly related to prolonged diarrhea. Diarrhea causes fluid loss, leading to hypotension or normal blood pressure, not elevated readings, making this an unlikely finding for a patient with dehydration from diarrhea.

Choice B reason: Abdominal distention is less likely with diarrhea, which typically reduces bowel contents. Distention may occur in conditions like bowel obstruction, not fluid loss from diarrhea, making this an incorrect expected finding for this patient’s condition.

Choice C reason: Tenting of the skin, indicating poor skin turgor, is expected with prolonged diarrhea due to dehydration from fluid and electrolyte loss. This physical sign reflects reduced tissue hydration, making it a key assessment finding for a patient with ongoing diarrhea.

Choice D reason: A heart rate of 62 beats/min is normal and not expected in diarrhea, which causes tachycardia due to dehydration and compensatory sympathetic activation. A low or normal heart rate is inconsistent with fluid loss, making this an incorrect finding.