A nurse is providing discharge teaching about lymphedema prevention to a client who is 2 days postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include?
Apply lotion to the incisional site twice daily.
Avoid measuring blood pressure on the affected arm.
Apply deodorant under the affected arm daily.
Avoid lifting objects greater than 5.4 kg (12 lb).
The Correct Answer is B
Choice A rationale:
Applying lotion to the incisional site may not be recommended as it could potentially irritate the incision or interfere with wound healing.
Choice B rationale:
Avoiding blood pressure measurements on the affected arm is important to prevent compromising lymphatic flow and potentially exacerbating lymphedema, a common complication after a modified radical mastectomy.
Choice C rationale:
Applying deodorant under the affected arm is discouraged, as it may contain chemicals that could irritate the surgical area.
Choice D rationale:
While lifting heavy objects is generally discouraged after surgery, the specific weight mentioned (5.4 kg or 12 lb) is not consistently supported as a limitation in post- mastectomy care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
A blood pressure of 78/60 mm Hg is indicative of hypotension which is a common complication of anorexia nervosa. However. the low body temperature takes precedence
Choice B rationale:
Weight loss of 20% over the last 6 months is concerning but may not be an immediate indicator for acute care admission.
Choice C rationale:
An apical pulse rate of 50/min is bradycardia, which can be a result of anorexia nervosa, but it may not be an immediate indicator for acute care admission unless the client is symptomatic.
Choice D rationale:
A body temperature of 35.5°C (95.9°F) is below a normal range signfyng hypothermia which needs immedate intervention.
Correct Answer is C
Explanation
Choice A rationale:
Asterixis is a hand-flapping tremor that can be associated with hepatic encephalopathy, not pancreatic cancer.
Choice B rationale:
Weight gain is not typically associated with pancreatic cancer and may not be a relevant manifestation to include.
Choice C rationale:
Abdominal pain is a common manifestation of pancreatic cancer and should be included in the teaching.
Choice D rationale:
Constipation is not typically associated with pancreatic cancer and may not be a relevant manifestation to include.
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