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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Carvedilol is not the correct medication. Carvedilol is a beta-blocker used for heart conditions, and there is no specific need to withhold it following a CT scan with contrast media.
Choice B Reason:
Clopidogrel is not the correct medication. Clopidogrel is an antiplatelet medication, and there is no specific need to withhold it following a CT scan with contrast media.
Choice C Reason:
Metformin is the correct medication. The nurse should instruct the client to withhold metformin for 48 hours following a CT scan with contrast media. Contrast media used in imaging procedures can potentially cause kidney damage, and when combined with metformin, there is a risk of a serious condition called lactic acidosis. Withholding metformin for 48 hours after the procedure helps prevent this risk.
Choice D Reason:
Furosemide is not the correct medication. - Furosemide is a diuretic, and there is no specific need to withhold it following a CT scan with contrast media.
Correct Answer is B
Explanation
Choice A reason:
Checking the client's vital signs is not appropriate. Checking vital signs is important to assess the severity of the reaction and monitor the client's overall condition.
Choice B reason:
Stopping the infusion is appropriate. Stopping the infusion is crucial to prevent further administration of the blood product that might be causing the adverse reaction. Once the infusion is stopped, the nurse can assess the client's condition more thoroughly and determine the appropriate steps to take next.
Choice C reason:
Collecting a urine sample is not appropriate. While urine sample collection may be important to assess for hemolysis (breakdown of red blood cells), it's not the first action to take. Stopping the infusion and assessing the client's vital signs are more immediate priorities.
Choice D reason:
Administering oxygen to the client is not appropriate. Providing oxygen might be necessary if the client is experiencing respiratory distress, but it's not the first action to take. Stopping the infusion and assessing the situation before providing additional interventions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today