A nurse evaluates the condition of the wound and determines that the staples or sutures should remain in place if:
A. The wound edges are separated
B. There is no drainage or erythema present
C. The client is anxious about their removal
D. A cosmetically aesthetic result would not be achieved
A
A. Assess healing ridge and skin integrity of suture line for uniform closure of wound edges, normal color, and absence of drainage and inflammation, which indicates adequate wound healing for support of internal structures without continued need for sutures or staples. If wound edges are separated or signs of infection are present, wound has not healed properly.
B. Absence of drainage and erythema would indicate sutures are ready for removal.
C. Steps would be taken to relieve the client's anxiety, but suture removal is based on the condition of the wound.
D. Timing of suture removal is based on adequate wound healing.
You might also like to view...
When explaining what is occurring when their child has an acute bronchial asthma attack, the nurse will emphasize that which mediator is primarily responsible for the bronchial constriction?
A) Tree pollen B) Mold dust C) Histamine D) T-lymphocyte proliferation
The nurse completes a physical assessment of a newborn. Which finding should the nurse identify as being abnormal?
A) Abdomen slightly protuberant B) Clear drainage at the base of the umbilical cord C) Bowel sounds present at two to three per minute D) Liver palpable 2 cm under the right costal margin
Which of the following is correct regarding pursuers of excellence?
a. value themselves for what they do b. correct mistakes, then learn from them c. learn from failure d. enjoy meeting high standards within reach
A client arrives in the Emergency Department with an overdose from benzodiazepines. What circumstance would cause the nurse to anticipate death of this client?
1. Benzodiazepines combined with a CNS stimulant 2. Has never taken a benzodiazepine before 3. Took a high dose of benzodiazepines 4. Has taken a benzodiazepine with a CNS depressant