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 ["14"]
Explanation
154 lbs ÷ 2.2 lbs/kg = 70 kg
20 units/kg * 70 kg = 1400 units
1400 units ÷ 25,000 units/250 mL = 14 mL
Therefore, the nurse will administer 14 mL of Heparin.
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Allogeneic Transplant
Matched Donor: This refers to a donor who is not genetically identical to the recipient but has a similar tissue type. This can include unrelated donors who are matched through registries.
Sibling Donor: A sibling can be a potential donor if they have a matching tissue type. Since siblings share genes, there is a higher chance of finding a match.
Autologous Transplant
Self-Donor: In this type of transplant, the patient donates their own stem cells before undergoing treatment (such as chemotherapy or radiation). These cells are then stored and re-infused after treatment to help the body recover.
Syngeneic Transplant
Twin Donor: This involves a donor who is an identical twin. Since identical twins have the same genetic makeup, there is a perfect match, reducing the risk of graft-versus-host disease (GVHD).
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