The nurse evaluates the surgical incision before removing the client's staples. Which client data does the nurse use to decide that staple removal is contraindicated for now?

Question

1. Increased risk of visible scarring
2. Small open area on incisional line
3. Site without drainage or erythema
4. Client anxious about staple removal

Answer 1

2
2. The nurse avoids removing staples from an incision with an open area because this potentially indicates the incision has delayed healing. If the nurse removes the staples too soon, the risk of infection increases from wound dehiscence or evisceration.
1. The method of wound closure, progression of healing, and client nutritional status determines scarring; staple removal generally has no effect on scarring.
3. A surgical incision without drainage or redness has clinical indicators consistent with a healing wound.
4. Clients are frequently anxious about procedures perceived as potentially painful, so the nurse instructs the client to expect a stinging sensation.