A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?
"I should expect less than 25 mL of secretions per day in the drainage devices."
"I will perform strength-building arm exercises using a 15-pound weight."
"I will keep my left arm flexed at the elbow as much as possible."
"I will have to wait 2 months before additional saline can be added to my breast expander."
The Correct Answer is A
A. Less than 25 mL of secretions per day in the drainage devices is an expected finding after surgery. The nurse should instruct the client to monitor the drainage and report if the output exceeds this amount, as it could indicate a complication.
B. Performing strength-building arm exercises using a 15-pound weight is not recommended immediately after surgery. The client should start with gentle range-of-motion exercises and gradually increase the intensity, but heavy weightlifting should be avoided in the early recovery period.
C. Keeping the left arm flexed at the elbow for prolonged periods is not recommended. The client should be encouraged to perform exercises to prevent stiffness and improve mobility in the affected arm, but excessive flexion can lead to contractures.
D. The client may begin the process of saline expansion in the breast expander soon after surgery, typically within a few weeks. Waiting 2 months may be too long, as expansion is often started earlier to avoid complications such as capsular contracture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A sore throat is a common and expected side effect following extubation. It typically resolves on its own and does not require immediate intervention.
B. Rhonchi are low-pitched, rattling sounds that are usually caused by the presence of mucus in the larger airways. While they can indicate airway obstruction, they are not as urgent as stridor.
C. A SaO2 of 92% is slightly below the normal range (typically 95-100%), but it is not an immediate emergency. The nurse should continue monitoring oxygen levels and intervene if they drop further.
D. Stridor is a high-pitched, wheezing sound caused by obstruction or narrowing of the upper airway. It is a medical emergency and requires immediate intervention to prevent complete airway obstruction.
Correct Answer is D
Explanation
A. While the bandage may provide some support to the surgical site, its primary purpose is not to keep sutures from loosening.
B. The bandage does not directly prevent wound infection; its main role is to manage edema and provide compression. Infection prevention is achieved through sterile technique and wound care.
C. The bandage does not prevent the client from seeing the surgical site; in fact, it is typically used for compression and edema management.
D. The primary purpose of the elastic bandage is to control swelling (edema) and promote proper shaping of the residual limb. This helps prevent complications and prepares the limb for prosthetic fitting.
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