A client returns to the surgical unit following a right modified radical mastectomy with dissection of axillary lymph nodes. An appropriate nursing intervention in the postoperative care for the client includes:
changing the surgical dressing when it becomes saturated with drainage.
encouraging the client to obtain permanent breast prosthesis as soon as she is discharged from the hospital.
placing a limb alert bracelet on the right wrist as warning against blood pressure or venipunctures.
teaching the client to use the prescribed patient-controlled analgesia (PCA) every 20 mintues for the best pain relief.
The Correct Answer is C
A. While it's important to monitor the surgical dressing, changing it too frequently can increase the risk of infection and disrupt healing. Instead, nurses typically assess the dressing regularly and only change it if it's overly saturated or if ordered by a physician. It’s essential to follow specific protocols regarding dressing changes.
B. A While breast prostheses can be an important part of post-mastectomy care for some clients, it is usually recommended that clients wait until they have fully healed and received counseling regarding their options. Immediate encouragement may be premature, as physical and emotional adjustments take time after surgery.
C. This is an appropriate intervention. After axillary lymph node dissection, there is a risk of lymphedema in the affected arm. Placing a limb alert bracelet serves as a reminder to healthcare providers to avoid taking blood pressure or performing venipunctures on the affected arm, thus helping prevent complications.
D. While PCA can be an effective method for managing postoperative pain, the timing and dosage should be based on the specific prescription and the client's individual needs. It’s crucial to educate the client about the PCA device and its use, but the specific interval may vary based on the medication's parameters and the patient's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A negative output would imply that the client has produced less urine than the irrigation received, which is not the case here.
B. The true urine output is 675 mL, calculated by subtracting the irrigation amount from the total urine collected.
C. The calculation does not support this value, as it does not accurately reflect the total urine output after accounting for the irrigation.
D. Similar to option A, a negative value does not apply here since the urine output exceeds the irrigation amount.
Correct Answer is A
Explanation
A. After a thyroidectomy and when receiving levothyroxine, it is essential for the patient to have regular follow-ups and blood tests (specifically TSH and free T4 levels) to ensure the dosage of levothyroxine is appropriate and to monitor for any complications related to the thyroid hormone levels.
B. Levothyroxine is a thyroid hormone replacement and, when taken appropriately, should help maintain a normal metabolism, potentially preventing weight gain. Weight changes can occur, but they are more likely to be due to improper dosing or underlying issues rather than a direct side effect of the medication itself.
C. Levothyroxine should be taken on an empty stomach, typically 30 to 60 minutes before breakfast, to ensure optimal absorption. Taking it with food can reduce its effectiveness.
D. While there are no strict dietary restrictions for most patients on levothyroxine, certain foods (such as those high in soy or fiber) can interfere with absorption if consumed around the time of taking the medication. Patients should be informed to take levothyroxine consistently and to wait a while before consuming certain foods that may impact absorption.
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