A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse. "I'm not sure I want to have a mastectomy." Which of the following statements should the nurse make?

Choice A reason:

May operate a motor vehicle when no longer taking analgesics is appropriate. This option could still potentially be a concern. While the patient might not be taking analgesics, the halo device's restrictions on neck movement could still impact their ability to safely operate a motor vehicle. So, this option might still need clarification with the provider.

Choice B reason:

Increase Intake of fibre-rich foods. This option is not related to the use of a halo device. Increasing fibber intake is generally a positive dietary recommendation, and it doesn't directly pertain to the halo device or the patient's discharge instructions.

Choice C reason:

May place a small pillow under the head when sleeping. This option is incorrect because using a small pillow under the head when sleeping is a common practice for patients with halo devices. It helps to maintain proper alignment and reduce discomfort while sleeping.

Choice D reason:

Take tub baths instead of showers. This option is incorrect because taking tub baths instead of showers is a common recommendation for patients with halo devices. The halo device must be kept dry to prevent complications. Showering might increase the risk of water seeping into the halo vest, whereas taking a tub bath could help in maintaining dryness around the device.

Choice A reason:

Listening to the client's bowel sounds should not be implemented. While assessing bowel sounds is important, it is not the highest priority in this situation. The client's low serum potassium level indicates the potential for serious cardiac arrhythmias, so actions related to monitoring and addressing this electrolyte imbalance are more critical.

Choice B reason:

Initiate cardiac monitoring for the client is the correct answer. A serum potassium level of 2.8 mEq/L is significantly low and can lead to life-threatening cardiac arrhythmias. Initiating cardiac monitoring is crucial to assess the client's heart rhythm and ensure that any potential abnormalities are identified promptly.

Choice C reason:

Check the client's hand grasps should not be implemented. Assessing the client's hand grasps can provide information about muscle strength, but it is not the immediate priority when the client has a critically low potassium level.

Choice D reason:

Administer an IV potassium drip should not be implemented. Administering IV potassium is important for correcting the potassium imbalance, but the priority is to assess and monitor the client's cardiac status first. Rapid administration of potassium can lead to cardiac arrhythmias, so it's important to ensure the heart's stability through cardiac monitoring before administering potassium.