The nurse plans to remove the client’s sutures. Which action demonstrates appropriate standards of care? Select all that apply

Use clean technique.

Grasp the suture at the knot with a pair of forceps.

Place the curved tip of the suture scissors under the suture as close to the skin as possible.

Pull the suture material that is visible beneath the skin during removal.

Remove alternate sutures first.

Answer and Explanation

Correct Answer : B,C,E

The priority is to remove nonabsorbable sutures without injuring newly formed tissue or introducing contamination. That means assessing the wound first, using appropriate technique and instruments, lifting the knot, cutting the stitch close to the skin, and extracting the suture so contaminated external material is not pulled back through the wound.

Rationale for correct answers:

2. Grasp the suture at the knot with a pair of forceps: Lift the knot gently with forceps to expose the loop, stabilize the stitch, and allow safe placement of scissors beneath the suture for cutting. This minimizes trauma to the wound edges.

3. Place the curved tip of the suture scissors under the suture as close to the skin as possible: Cutting close to the skin limits contamination and eases atraumatic removal.

5. Remove alternate sutures first: Removing every other suture first helps maintain some wound support and lets you check approximation/healing as you go; if edges separate, you can stop and notify the provider. If the wound is well healed, sometimes all may be removed at once.

Rationale for incorrect answers:

1. Use clean technique: Suture removal is usually a sterile procedure.

4.Pull the suture material that is visible beneath the skin during removal: You must not pull the contaminated visible external portion of the suture through underlying tissue- that would drag external contaminants into the wound.

Take home points:

Cut close, pull carefully.
Always cut the suture as close to the skin as possible and remove the suture in a way that prevents dragging contaminated external material back through subcutaneous tissue.

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Correct Answer is B

Explanation

Normal aging decreases lung elasticity, chest wall compliance, and vital capacity. These changes make older adults more prone to hypoventilation, atelectasis, and respiratory infections after anesthesia. Nursing care must focus on pulmonary hygiene: turning, coughing, deep breathing, and using incentive spirometry.

Rationale for correct answer:

2. Turn, cough, and deep breathe every 4 hours: Reduced vital capacity in older adults increases the risk of atelectasis and pneumonia postoperatively. Encouraging frequent deep breathing and coughing expands alveoli, promotes secretion clearance, and improves oxygenation.

Rationale for incorrect answers:

1. Take and record vital signs every shift: Vital signs help monitor overall stability but do not directly address the physiologic change of reduced vital capacity.

3. Encourage increased intake of oral fluids: Fluids are important for hydration and mucous membrane health, but they don’t directly improve vital capacity.

4. Assess bowel sounds daily: Monitoring bowel function is important after surgery, but it does not address the pulmonary risks related to decreased lung function.

Take home points:

Older adults have decreased lung reserve, making pulmonary complications more likely after surgery.
Frequent pulmonary exercises (turn, cough, deep breathe, incentive spirometry) are the most effective interventions to prevent atelectasis and pneumonia.

A. Delayed ambulation B. Reduced ventilation C. Catheter-associated urinary tract infection D. Retained pulmonary secretions E. Reduced appetite

Correct Answer is ["A","B","D","E"]

Explanation

risk of complications. It reduces ventilation since the patient avoids deep breaths, leading to shallow breathing. Ineffective coughing due to pain results in retained pulmonary secretions, which predispose to atelectasis or pneumonia. Severe pain also reduces appetite by impairing gastrointestinal function.

Rationale for correct answers:

1. Delayed ambulation: Pain that is uncontrolled makes patients reluctant or unable to get out of bed. This can contribute to immobility complications such as deep vein thrombosis, pneumonia, or pressure injuries.

2. Reduced ventilation: Pain (especially abdominal or thoracic surgical pain) makes patients reluctant to take deep breaths. This can lead to shallow breathing, poor oxygen exchange, and hypoxemia. It increases the risk for respiratory complications.

4. Retained pulmonary secretions: Pain discourages effective coughing and deep breathing. As a result, secretions accumulate in the lungs, which can lead to atelectasis and secondary pneumonia.

5. Reduced appetite: Severe pain can activate stress responses and decrease gastrointestinal motility, leading to nausea, poor appetite, and delayed nutrition. Good pain control improves recovery by allowing earlier intake of food and fluids.

Rationale for incorrect answers:

3. Catheter-associated urinary tract infection: While UTIs are a postoperative risk, they are linked to indwelling catheter duration, not unmanaged pain. Pain control does not directly prevent or cause this complication.

Take home points:

Poorly controlled pain impairs breathing, mobility, and nutrition.
Effective pain management promotes faster recovery and prevents pulmonary and mobility complications.

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The nurse plans to remove the client’s sutures. Which action demonstrates appropriate standards of care? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Older adults often have reduced vital capacity as a result of normal physiologic changes. Which nursing intervention would be most important for the postoperative care of an older surgical patient specific to this change?

Correct Answer is B

Explanation

Correct Answer is ["A","B","D","E"]

Explanation

A nurse cares for a postoperative patient in the PACU. Upon assessment, the nurse finds the surgical dressing is saturated with serosanguineous drainage. Which two interventions are a priority? Select all that apply

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The client’s postoperative orders state “diet as tolerated.” The client has been NPO. The nurse will advance the client’s diet to clear liquids based on which assessment? Select all that apply

Mr. Moreno has had a surgical procedure that necessitated a thoracic incision. The nurse anticipates that he will have a higher risk for postoperative complications involving which body system?

The nurse plans to remove the client’s sutures. Which action demonstrates appropriate standards of care? Select all that apply

Which of the following surgical patients is at a greater risk for alterations in body image?

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The nurse is explaining the rationale for performing leg exercises after surgery. Which reason would the nurse include in the explanation?