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 A
Explanation
Choice A Reason:
Vigorously strip the chest tube twice daily. The nurse should clarify the prescription to "vigorously strip the chest tube twice daily" with the provider. Stripping or milking a chest tube is generally not recommended, as it can cause damage to the tube and lead to complications. The movement of fluid and air in the chest tube should be allowed to occur naturally based on the patient's own respiratory effort.
Choice B Reason:
Assist the client out of bed three times daily - This is a reasonable activity for a client with a chest tube, as mobility and deep breathing can help prevent complications.
Choice C Reason:
Notify the provider when tiddling ceases - Monitoring for tiddling (fluctuations in the water seal chamber with respiration) and notifying the provider when tiddling stops is important, as it might indicate a potential issue with the chest tube placement or functioning.
Choice D Reason:
Administer morphine 2 mg IV bolus every 3 hr PRN for pain - Administering pain relief for the client is appropriate and helps manage their comfort. Pain control is important to encourage deep breathing and prevent complications related to shallow breathing due to pain.
Correct Answer is A
Explanation
Choice A reason:
Measuring the client's blood pressure is appropriate. Assessing the client's blood pressure is a crucial initial step to determine the client's perfusion status and the impact of the bradycardia on their circulation. Sinus bradycardia can result in decreased cardiac output and compromised blood flow to various organs. Measuring the blood pressure helps the nurse evaluate the severity of the bradycardia and its potential effects on the client's overall condition.
Choice B Reason:
Administering atropine to the client is inappropriate. Atropine is a medication that can be used to increase heart rate in bradycardic situations. However, assessing blood pressure comes first to ensure that the blood pressure isn't critically low before administering medications.
Choice C reason:
Initiating IV fluid therapy for the client is inappropriate. Fluid therapy might be necessary to improve perfusion in certain cases, but assessing blood pressure should be done first to guide treatment decisions.
Choice D Reason:
Preparing the client for temporary pacing is inappropriate Temporary pacing might be required in severe cases of bradycardia, but again, assessing blood pressure takes priority to determine the urgency of intervention.
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