A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?

Obtain blood pressure readings using the client's right arm.

Limit range-of-motion exercises with the affected arm.

Keep both arms below the level of the client's heart.

Use the client's left arm to obtain blood samples.

Answer and Explanation

The Correct Answer is D

The client had a right radical mastectomy, which can lead to lymphedema, a buildup of fluid that can cause swelling in the arm. Using the client's left arm to obtain blood samples can help prevent injury to the affected arm and reduce the risk of lymphedema. Obtaining blood pressure readings with the client's left arm is also recommended. Range-of-motion exercises are important to prevent stiffness, and elevating the affected arm can help reduce swelling.

A: Obtaining blood pressure readings with the client's right arm can cause injury and increase the risk of lymphedema.

B: Limiting range-of-motion exercises can lead to stiffness and may not prevent lymphedema.

C: Keeping both arms below the level of the client's heart can help reduce swelling, but does not directly prevent lymphedema.

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Correct Answer is D

Explanation

The correct answer is choice D, Describe the food placement as though the plate were a clock. When delivering the client's meal tray, the nurse should describe the food placement as though the plate were a clock to help the client know where the food is located. This helps the client be more independent and participate actively at mealtime. Choice A is incorrect because arranging for assistive personnel to feed the client may take away the client's independence. Choice B is incorrect because discouraging conversations during the client's mealtime may make the client feel isolated. Choice C is incorrect because providing the client with small-handled adaptive utensils may not help the client locate food on the plate.

Other choices:

A. Arrange for assistive personnel to feed the client: Arranging for assistive personnel to feed the client may take away the client's independence.

B. Discourage conversations during the client's mealtime: Discouraging conversations during the client's mealtime may make the client feel isolated.

B. Provide the client with small-handled adaptive utensils: Providing the client with small-handled adaptive utensils may not help the client locate food on the plate.

A. Tachycardia. B. Bloating. C. Hypertension. D. Irritability.

Correct Answer is ["A","D"]

Explanation

The correct answer is Choice A, Choice D.

Choice A rationale: Tachycardia, or an increased heart rate, is a common symptom of dehydration in infants. The body attempts to maintain adequate blood circulation despite reduced fluid volume by increasing the heart rate, which is a compensatory mechanism.

Choice B rationale: Bloating is not typically associated with dehydration in infants. Dehydration usually results in symptoms like dry mucous membranes and decreased skin turgor, rather than gastrointestinal symptoms like bloating.

Choice C rationale: Hypertension, or high blood pressure, is uncommon in dehydrated infants. Dehydration generally leads to hypotension (low blood pressure) due to decreased fluid volume in the circulatory system, which can result in reduced blood pressure.

Choice D rationale: Irritability is a frequent symptom of dehydration in infants. Reduced fluid intake and electrolyte imbalances can cause discomfort and distress, leading to irritability and increased fussiness in dehydrated infants.

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A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a visually impaired client. What action should the nurse take when delivering the client's meal tray?

Correct Answer is D

Explanation

Which of the following symptoms should a nurse expect to find when assessing an infant who is dehydrated in an emergency department? Select all that apply

Correct Answer is ["A","D"]

Explanation

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