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 ["7"]
Explanation
(desired dose * volume of solution) / (concentration of drug * time) = rate.
For an infusion of 7 units per hour with a concentration of 100 units in 100 mL, the calculation would be: (7 units/hour * 100 mL) / (100 units * 1 hour) = 7 mL/hour.
Therefore, the nurse should set the IV pump to 7 mL per hour to deliver a continuous infusion of insulin at the prescribed rate.
Correct Answer is C
Explanation
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.
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