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 will have to wait 2 months before additional saline can be added to my breast expander."
"I should expect less than 25 mL of secretions per day in the drainage devices."
"I will keep my left arm flexed at the elbow as much as possible."
"I will perform strength-building arm exercises using a 15-pound weight."
The Correct Answer is B
The client should expect less than 25 mL of secretions per day in the drainage devices before they are removed, usually within 7 to 10 days after surgery. This indicates that the wound is healing and there is no excessive fluid accumulation in the surgical site. The other statements are incorrect and indicate a need for further teaching. The client should not wait 2 months before additional saline can be added to the breast expander, as this may delay the reconstruction process and increase the risk of infection or contracture.
The client should keep the left arm elevated on a pillow and avoid flexing it at the elbow, as this may impair lymphatic drainage and cause edema or pain. The client should perform gentle range-of-motion exercises with the left arm and avoid lifting heavy objects such as a 15-pound weight, as this may strain the incision or cause bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A halo device is a type of external fixation device that immobilizes the cervical spine after an injury or surgery. The device consists of a metal ring attached to four metal rods that are secured to a vest worn by the client. The device limits the movement of the head and neck, which can impair the client's ability to drive safely. The nurse should clarify with the provider if the client can operate a motor vehicle while wearing the halo device, as this may pose a risk for injury to the client and others on the road.
Placing a small pillow under the head when sleeping, increasing intake of fiber-rich foods, and taking tub baths instead of showers are all appropriate instructions for a client with a halo device
Correct Answer is D
Explanation
A flat lesion with irregular borders is one of the signs of melanoma, a type of skin cancer that arises from melanocytes, the cells that produce pigment. Other signs of melanoma include asymmetry, color variation, diameter greater than 6 mm, and evolution or change over time. The other options are more characteristic of other types of skin cancer or benign lesions.
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