A nurse is caring for a client who is 6 hr postoperative following a modified radical mastectomy. The client has a portable wound bulb suction device in place. Which of the following actions should the nurse take?
Maintain a constant, gentle suction on the drainage device.
Place the client in the supine position while resting in bed.
Prepare to remove the drainage tube 24 hr after the procedure.
Notify the provider for drainage of 25 mL in 24 hr.
The Correct Answer is A
A. Maintain a constant, gentle suction on the drainage device: A portable wound bulb suction device is used to remove blood and serous fluid, prevent hematoma or seroma formation, and promote wound healing. Maintaining constant, gentle suction ensures effective drainage and reduces the risk of complications such as infection or fluid accumulation.
B. Place the client in the supine position while resting in bed: After a mastectomy, clients are typically positioned with the head of the bed elevated and the affected arm supported on a pillow to reduce swelling and promote comfort. Supine positioning without support may increase tension on the surgical site and impair drainage.
C. Prepare to remove the drainage tube 24 hr after the procedure: Drainage tubes are usually removed when output is minimal, often 24–48 hours or longer depending on the volume and type of drainage. Removing the tube at a fixed 24-hour mark may be premature and could increase the risk of fluid accumulation.
D. Notify the provider for drainage of 25 mL in 24 hr: Drainage of 25 mL in 24 hours is minimal and typically does not require provider notification. Normal early postoperative drainage is expected, and the nurse should continue routine monitoring and documentation rather than escalate care for this amount.
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Related Questions
Correct Answer is A
Explanation
A. Health department data and statistics reports: Local or state health departments routinely collect and publish epidemiological data, including incidence and prevalence rates of communicable diseases like tuberculosis. These reports provide reliable, up-to-date statistics that are essential for planning and evaluating public health programs.
B. Expert opinion from local health care providers: Expert opinion can provide insights into trends or clinical observations, but it is anecdotal and not sufficient for calculating incidence rates. Public health planning requires data that is systematically collected and analyzed.
C. Browsing an internet search engine: While internet searches may yield general information, the results may not be accurate, up-to-date, or specific to the local population. Official health department sources are more reliable for incidence data.
D. Clinical guidelines from a professional organization: Clinical guidelines provide recommendations for diagnosis, treatment, and management, but they do not usually include local incidence statistics. They are not a primary source for epidemiological data.
Correct Answer is B
Explanation
A. Discuss the client's strengths and weaknesses with the client: Exploring strengths can be part of long‑term therapeutic support, but it does not address the immediate concern of a possible suicidal statement. Before engaging in broader discussions, the nurse must first determine the meaning and seriousness of the client’s words.
B. Ask the client to clarify what they mean: Asking the client to clarify their statement is the priority because it directly assesses the risk of self‑harm. This step helps the nurse determine whether the client has suicidal ideation, intent, or a plan. Clear assessment of safety concerns must occur before any other supportive or therapeutic interventions.
C. Ask the client if they have been taking their medication as prescribed: Medication adherence is important, but it does not address the urgency of a suicidal comment. Focusing on medications can divert attention from immediate safety needs and delay critical assessment of suicidal risk.
D. Remind the client that it is not the end of life: Offering reassurance without assessing the client’s emotional state can minimize their feelings and discourage further communication. This response may shut down dialogue and does not evaluate the level of risk, which is the most urgent priority.
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