A nurse is providing discharge teaching to a client following a modified left radical mastectomy with a breast expander. Which of the following statements by the client indicates an understanding of the teaching?
“will keep my left arm flexed at the elbow as much as possible"
“will have to wait 2 months before additional saline can be added to my breast expander"
“should expect less than 25 ml of secretions per day in the drainage devices."
“will perform strength-building arm exercises using a 15-pound weight."
The Correct Answer is C
Choice A reason:
"will keep my left arm flexed at the elbow as much as possible": This statement is incorrect because after a mastectomy, it's important to promote full range of motion in the affected arm to prevent complications like contractures and lymphedema.
Choice B reason:
“will have to wait 2 months before additional saline can be added to my breast expander" Typically, the process of adding saline to a breast expander begins much sooner, often within a few weeks after surgery, depending on the individual’s healing progress and the surgeon’s protocol.
Choice C reason:
"should expect less than 25 ml of secretions per day in the drainage devices":After a mastectomy, drainage devices are often placed to prevent fluid accumulation. The client should be aware that once the drainage decreases to less than 25 ml per day, it may be an indication that the drain can be removed. This shows an understanding of what to monitor postoperatively.
Choice D reason:
"will perform strength-building arm exercises using a 15-pound weight": This statement is not appropriate, especially shortly after surgery. Gradual and gentle strength-building exercises are recommended, and using a 15-pound weight could be too strenuous and potentially harmful.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
NG tube with suction apparatus should not be recommended. NG tubes and suction are not routine equipment for managing cystic fibrosis. They might be used for other medical conditions, such as digestive issues or nutritional support.
Choice B Reason:
Chest tube with a drainage system should not be recommended -. Chest tubes and drainage systems are used to manage conditions like pneumothorax or pleural effusion, which are not directly related to cystic fibrosis.
Choice C Reason:
A chest physiotherapy (CPT) vest, also known as a high-frequency chest wall oscillation (HFCWO) vest, is commonly used by clients with cystic fibrosis to help clear mucus from the lungs. The vest vibrates at high frequency, loosening the mucus and making it easier for the client to cough it up, thus helping to manage respiratory symptoms and reduce the risk of infections.
Choice D Reason:
A peak flow meter is typically used for clients with asthma to measure the maximum speed of exhalation, which helps in assessing asthma control. While it can be useful for monitoring lung function, it is not specific to cystic fibrosis, where the primary concern is airway clearance rather than peak flow measurement.
Correct Answer is D
Explanation
Choice A Reason:
Applying lotion between the toes - Applying lotion between the toes can create a moist environment that may increase the risk of fungal infections. Lotion application should be done on the tops and bottoms of the feet, avoiding the spaces between the toes.
Choice B Reason:
Inspecting the feet every other day - Daily foot inspections are recommended for individuals with diabetes to identify any changes or abnormalities early and prevent potential complications.
Choice C Reason:
Soaking the feet twice a day - Excessive soaking of the feet can lead to maceration of the skin and increase the risk of infection, so it's generally not recommended. Regular washing with mild soap and water is sufficient for foot hygiene.
Choice D Reason
Trim toenails straight across When providing discharge teaching about foot care to a client with diabetes, the nurse should include information about proper foot care practices to prevent complications. Trimming toenails straight across is recommended to avoid ingrown toenails and potential injury. This reduces the risk of foot complications that can arise due to diabetes-related circulatory and neuropathic changes.
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