A client is discharged to home after a modified radical mastectomy with two drainage tubes. Which statement by the client would indicate that further teaching is needed?

"I am glad that these tubes will fall out at home when I finally shower."

"I should measure the drainage each day to make sure it is less than an ounce (30 mL)."

"I should be careful how I lie in bed so that I will not kink the tubing."

"If there is a foul odor from the drainage, I will contact my primary health care provider."

Answer and Explanation

The Correct Answer is A

A. This statement indicates that the client may not fully understand the care required for the drainage tubes. Drainage tubes typically do not "fall out" on their own; they need to be removed by a healthcare provider. The client should be instructed to care for the tubes, monitor drainage, and report any concerns to their healthcare provider.

B. It is appropriate to measure the drainage each day and report it if it exceeds the expected amount. This helps ensure that the surgical site is healing properly.

C. The client should be cautious with the positioning of the drainage tubes to avoid kinking or pulling, which could interfere with drainage and cause complications.

D. A foul odor from the drainage could indicate an infection, so it is appropriate for the client to contact their primary healthcare provider if this occurs.

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Correct Answer is D

Explanation

A. Testing the equipment with a smaller shock is unnecessary when preparing to defibrillate in an emergency.

B. Epinephrine is used in cases of cardiac arrest with no pulse, particularly in asystole or pulseless electrical activity (PEA), not immediately before defibrillation in ventricular fibrillation.

C. Synchronous mode is used for cardioversion, not for defibrillation. Defibrillation should be delivered in unsynchronized mode.

D. Before delivering a shock, it is essential to ensure that everyone, including the nurse, is clear of the client and any conductive surfaces like the bed. This prevents injury from the electrical shock.

A. Client reports a pain level of 3/10. B. Left groin has minimal bruising. C. Left leg with weakened pedal pulse and is cool to the touch. D. Blood pressure 154/78 mmHg.

Correct Answer is C

Explanation

A. A mild pain level of 3/10 is common after angioplasty and is not immediately concerning.

B. Minimal bruising at the groin is expected after this procedure and is not alarming.

C. A weakened pedal pulse and a cool leg could indicate compromised circulation, which is a serious concern post-angioplasty. Immediate assessment is needed to check for possible complications such as re-occlusion.

D. A blood pressure of 154/78 mmHg is somewhat elevated but not alarming.

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Test Name	Results	Reference Range
WBC	12, 000	4, 000- 11, 000
Na+	149 mEq/L	135-145 mEq/L
K+	5.0 mEq/L	3.5- 5.0 mEq/L
Cl-	110 mEq/L	96-106 mEq/L
pH	7.34	7.35-7.45
PaCO2	34 mmHg	35- 45 mmHg
PaO2	78 mm Hg	80-100 mmHg
HCO3	21 mEq/L	22- 26 mEq/L

A client is discharged to home after a modified radical mastectomy with two drainage tubes. Which statement by the client would indicate that further teaching is needed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which intervention is appropriate for the nurse to perform prior to defibrillating this client?

Correct Answer is D

Explanation

The nurse assesses a client who just returned to the recovery area after undergoing a balloon angioplasty to improve circulation to the left leg. What assessment finding is the most concerning?

Correct Answer is C

Explanation

A client who has been anticoagulated with warfarin (Coumadin) has been admitted for gastrointestinal bleeding. The history and physical examination indicates that the client may have been taken too much warfarin. The nurse anticipates that client will receive which antidote?

When evaluating the effectiveness of preoperative teaching with a client scheduled for coronary artery bypass graft (CABG) surgery using the internal mammary artery, the nurse determines that additional teaching is needed when the client says which of the following?

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