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 B

Explanation

Choice A reason:

Listening to the client's bowel sounds should not be implemented. It is important for assessing the gastrointestinal status, but the priority in this situation is to address the potential cardiac complications of hypokalaemia.

Choice B reason:

Initiating cardiac monitoring for the client should be implemented. A serum potassium level of 2.8 mEq/L is significantly low (normal range is typically around 3.5-5.0 mEq/L). Low potassium levels, known as hypokalaemia, can lead to serious cardiac arrhythmias and other complications. Therefore, the nurse should prioritize cardiac monitoring to assess for any potential changes or abnormalities in the client's heart rhythm due to the low potassium levels.

Choice C reason:

Checking the client's hand grasps should not be implemented. It is a test for muscle strength and can be indicative of hypokalaemia, but initiating cardiac monitoring is more critical at this point.

Choice D reason:

Administering an IV potassium drip may be necessary, but initiating cardiac monitoring takes precedence as the first action to ensure the client's heart rhythm is stable before addressing the potassium imbalance.

A. A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% B. A client who has multiple sclerosis and reports ataxia and vertigo C. A client who has left-sided paralysis and slurred speech from a prior stroke D. A client who has thrombocytopenia and reports a nosebleed

Correct Answer is A

Explanation

Choice A Reason:

A client who has chronic obstructive pulmonary disease and an oxygen saturation of 89% is correct. The nurse should attend to the client with chronic obstructive pulmonary disease and an oxygen saturation of 89% first. Oxygen saturation levels below 90% indicate significant hypoxemia and potential respiratory distress. The client with COPD is at risk for further worsening of their condition due to inadequate oxygenation. Therefore, addressing this client's low oxygen saturation is a priority to ensure their respiratory status is stabilized.

Choice B Reason:

A client who has multiple sclerosis and reports ataxia and vertigo is incorrect. While these symptoms need assessment and care, they are not indicative of an immediate life-threatening situation.

Choice CReason:

A client who has left-sided paralysis and slurred speech from a prior stroke is incorrect., While this client requires ongoing care, the immediate concern is lower in priority compared to addressing severe hypoxemia.

Choice DReason:

A client who has thrombocytopenia and reports a nosebleed is incorrect. Although a nosebleed can be concerning due to thrombocytopenia, it is not as immediately critical as addressing severe hypoxemia.

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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

A nurse is caring for a client who arrives at the emergency department and reports vomiting and diarrhea for the past 3 days. The client's serum potassium level is 2.8 mEq/L. Which of the following interventions should the nurse implement first?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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