Physiological Integrity—Physiological Adaptation

The nurse is preparing to remove a client’s abdominal stitches as ordered by the health care provider. Which is the correct action by the nurse?

Posted on by NCLEX.ME Nurse
  1. clean the stitches with soap and water before removing
  2. wash the hands and use gloves while removing the stitches
  3. wash the hands and use sterile technique when removing the stitches
  4. wear a gown, gloves, a mask, an eye shield, and shoe covers during the procedure
Number 3 is correct.
Rationale: Removing stitches is a sterile procedure. The nurse should wash her hands and use sterile technique when removing stitches. Soap and water is not sufficient for cleaning the stitches prior to removal. Washing the hands and using regular gloves is not sterile. The sterile field must be maintained during the procedure, which contraindicates the use of regular gloves. It is not necessary to wear a gown, a mask, gloves, an eye shield, and shoe covers unless the client is on contact precautions. Nothing in this question indicates that the client is on contact precautions.
NCLEX.ME Nurse