A nurse is providing discharge teaching to a client following a modified left mastectomy. Which statements by the client indicate an understanding of the teaching?

"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."

"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."

Answer and Explanation

The Correct Answer is B

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" This is the correct statement. Following a modified radical mastectomy with a breast expander, additional saline is often added gradually to the expander to stretch the skin and muscle for reconstruction. The waiting period between saline additions allows for healing and proper tissue expansion. This statement indicates that the client understands the postoperative care and timeline.

Choice C reason:

"should expect less than 25 ml of secretions per day in the drainage devices": This statement is not accurate because the drainage amount can vary, and 25 ml per day might not be an accurate estimate.

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.

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Correct Answer is C

Explanation

Choice A Reason:

Peripheral pulses 2+ bilaterally - This indicates good peripheral circulation and is not typically a concerning finding.

Choice B Reason:

Creatinine 0.8 mg/dL - A creatinine level of 0.8 mg/dL is within the normal range and does not indicate acute kidney failure.

Choice C Reason:

Urine specific gravity 1.045 A urine specific gravity of 1.045 is significantly elevated and could indicate concentrated urine, which might be a concern in a client with acute kidney failure. Elevated specific gravity could suggest dehydration, impaired kidney function, or other kidney-related issues. The nurse should report this finding to the provider for further evaluation and intervention.

Choice D Reason:

Weight gain 1.1 kg (2.4 lb) in 24 hr - While weight gain should be monitored closely in clients with kidney failure, 1.1 kg in 24 hours might not be an immediate concern, depending on the client's overall condition and baseline weight. However, it should still be followed up on in subsequent assessments.

A. Obtain consent for surgery. B. Insert an NG tube. C. Apply antiembolic stockings D. insert an indwelling armory catheter

Correct Answer is A

Explanation

Choice A reason:

Obtaining consent for surgery is the correct answer. Obtaining informed consent for surgery is a critical and ethical step to ensure the client's rights are respected and that necessary medical interventions can be performed. However, in cases where the client is unable to provide consent due to their level of intoxication, the nurse should follow established protocols for obtaining consent from a legal guardian or

Choice B reason:

Insert an NG tube is incorrect. Inserting a nasogastric (NG) tube might be a necessary step in preparing a client for surgery in certain cases, but it is not the top priority in this situation. Obtaining consent for surgery takes precedence.

Choice C reason:

Applying ant embolic stockings is incorrect. Applying ant embolic stockings, also known as compression stockings, is an important measure to prevent blood clots (deep vein thrombosis) during and after surgery. However, obtaining consent for surgery is more urgent in an emergency situation.

Choice D reason:

Inserting an indwelling urinary catheter is incorrect. Inserting a urinary catheter might be necessary to monitor the client's urinary output during surgery, but obtaining consent for surgery is the priority action.

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A nurse is providing discharge teaching to a client following a modified left mastectomy. Which statements by the client indicate an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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