A nurse is providing discharge teaching to a client who is 1 day postoperative following a right modified radical mastectomy. Which of the following instructions should the nurse include in the teaching?
Wear a bra with wire support.
Use deodorant under the affected arm.
Begin ball squeezing exercises.
Avoid using the affected arm for eating.
The Correct Answer is D
A. Wear a bra with wire support: This is not recommended immediately after a modified radical mastectomy, as it can put pressure on the surgical site and cause discomfort or interfere with healing. Instead, the client should wear a soft, supportive bra without underwire to provide comfort and support.
B. Use deodorant under the affected arm: Applying deodorant under the affected arm is generally not recommended immediately after surgery, as the area may be sensitive and the skin may be healing. The client should avoid applying deodorant until the surgical site has healed and they have consulted with their healthcare provider.
C. Begin ball squeezing exercises: While exercises to improve range of motion and strength in the affected arm are important after a mastectomy, initiating them on the first day postoperative may be too early. The client should follow the specific instructions provided by their healthcare provider regarding when to begin exercises and which exercises are appropriate.
D. Avoid using the affected arm for eating: This is the most appropriate instruction for the client. After a modified radical mastectomy, the affected arm may be temporarily restricted in movement or may be sensitive. To avoid strain or discomfort, the client should avoid using the affected arm for activities such as eating until they receive further guidance from their healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You should wear a snug-fitting bra continuously for 72 hours": Wearing a snug-fitting bra continuously for 72 hours can help suppress lactation by providing support and reducing stimulation to the breasts. This can help prevent milk production and engorgement.
B. "You should apply moist heat to your breasts four times per day": Moist heat can stimulate milk production and should be avoided when trying to suppress lactation.
C. "You should limit your fluid intake to 1 liter per day": Adequate hydration is important for overall health, and limiting fluid intake to 1 liter per day is not advisable, especially postpartum when hydration needs may be higher.
D. "You should manually express milk when engorgement occurs": Manual expression of milk can stimulate milk production and should be avoided when attempting to suppress lactation. If engorgement occurs, cold compresses or ice packs can be used to reduce discomfort without stimulating milk production.
Correct Answer is A
Explanation
A. Measure the legs with a tape measure to determine stocking size: Antiembolic stockings should fit properly to provide therapeutic compression without causing discomfort or impairing circulation. Measuring the legs accurately with a tape measure ensures the stockings fit appropriately and exert the correct amount of pressure to prevent deep vein thrombosis (DVT) and promote venous return.
B. Remove the stockings every 24 hr: Antiembolic stockings are typically worn continuously, especially during periods of immobility, to maintain consistent compression and prevent blood clots. Removing the stockings every 24 hours would interrupt the therapeutic effect and increase the client's risk of developing DVT.
C. Massage the legs before applying the stockings: Massaging the legs before applying antiembolic stockings is contraindicated, as it can dislodge blood clots and increase the risk of embolism. Additionally, massaging may cause trauma to the skin and exacerbate any existing circulatory issues.
D. Fold the stockings at the top if they are too long: Folding the stockings at the top if they are too long can create pressure points and compromise circulation, leading to discomfort and potentially exacerbating vascular issues. It is essential to ensure the stockings fit properly by selecting the appropriate size rather than folding them.
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