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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","F","G"]
Explanation
A. Administer betamethasone: Betamethasone is indicated to promote fetal lung maturity in a client at 31 weeks gestation at risk for preterm delivery. Administering corticosteroids reduces neonatal complications and is appropriate for this high-risk pregnancy.
B. Give antihypertensive medication: The client’s blood pressure readings (162/112 mm Hg and 166/110 mm Hg) indicate severe hypertension, which requires prompt management to prevent maternal complications such as stroke, eclampsia, or organ damage. Administering antihypertensives is a priority in controlling blood pressure.
C. Monitor intake and output hourly: Frequent monitoring of fluid balance is essential due to the risk of renal impairment from preeclampsia. Hourly intake and output helps detect oliguria or fluid retention, which can indicate worsening maternal status or impending complications.
D. Perform a vaginal examination every 12 hr: Routine vaginal examinations are avoided in clients with preeclampsia or severe hypertension due to the risk of inducing labor or causing trauma. Vaginal exams should be performed only when medically indicated.
E. Obtain a 24-hr urine specimen: Measuring proteinuria via a 24-hour urine collection helps evaluate the severity of preeclampsia and guides clinical management. This client has 3+ protein on urinalysis, confirming significant proteinuria.
F. Provide a low-stimulation environment: Reducing stimuli helps prevent exacerbation of headache, hypertension, and risk for seizures. A calm, quiet environment is a standard intervention for clients with severe preeclampsia.
G. Maintain bed rest: Bed rest with lateral positioning promotes uteroplacental perfusion, reduces blood pressure, and helps prevent complications such as eclampsia. The intervention supports maternal and fetal stability in the acute phase of severe preeclampsia.
Correct Answer is D
Explanation
A. Slurred speech: Slurred speech is typically associated with intoxication from central nervous system depressants, such as alcohol or opioids, rather than withdrawal. During withdrawal, the client is more likely to exhibit hyperactive or restless behavior.
B. Constricted pupils: Pupillary constriction (miosis) occurs with opioid intoxication. In contrast, opioid withdrawal usually causes dilated pupils (mydriasis) due to sympathetic nervous system overactivity.
C. Sedation: Sedation is a common effect of opioid use, not withdrawal. During withdrawal, clients are generally hyperalert, restless, and may experience insomnia rather than excessive sleepiness.
D. Yawning: Yawning is a classic sign of opioid withdrawal and reflects autonomic nervous system activation. It is often accompanied by lacrimation, rhinorrhea, sweating, and other early withdrawal symptoms.
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