A nurse is providing teaching to a client who is postoperative following a mastectomy of the left breast with axillary lymph node dissection. Which of the following exercises should the nurse instruct the client to start on the first postoperative day?
Tugging on a pulley rope with both hands.
Swinging a rope in a circular motion with the left hand.
"Walking”. up a wall with both hands.
Squeezing and releasing a ball in the left hand.
The Correct Answer is D
Choice A rationale:
Is not suitable for a client who has undergone a mastectomy with axillary lymph node dissection. This exercise may put a strain on the surgical site and cause discomfort or injury.
Choice B rationale:
Is also not appropriate for a postoperative mastectomy client. It involves using the left hand extensively, which could potentially disrupt the healing process and cause pain.
Choice C rationale:
Is not recommended for a postoperative mastectomy client. It involves significant upper body movement, which may not be well-tolerated after surgery, especially with lymph node dissection.
Choice D rationale:
This exercise is suitable for a postoperative mastectomy client as it helps in maintaining hand and arm mobility without putting excessive strain on the surgical site. It also aids in preventing complications like lymphedema, which is a potential concern after lymph node dissection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should instruct the client to place cellular phones on the ear opposite the side of the pacemaker to minimize the risk of electromagnetic interference. Although the risk of interference is low with modern pacemakers, it is still a precautionary measure. Placing the phone on the ear opposite the pacemaker reduces the likelihood of any potential electromagnetic interaction.
Choice B rationale:
The instruction in choice B, "Avoid showering for the first 2 weeks following surgery,”. is not appropriate. There is no need for the client to avoid showering after pacemaker insertion. In fact, maintaining good hygiene is essential to prevent infection at the incision site. The client can take a shower, but they should avoid soaking the incision area and patting it dry afterward.
Choice C rationale:
The instruction in choice C, "Avoid heavy lifting for 1 week following insertion,”. is not the best option. The recommended timeframe to avoid heavy lifting after a pacemaker insertion is usually around 4 to 6 weeks. This duration allows the surgical site to heal properly and reduces the risk of dislodging the pacemaker leads or causing damage.
Choice D rationale:
The instruction in choice D, "Stand at least 2 feet away while using a microwave,”. is not directly related to pacemaker care. While it is generally recommended to maintain a safe distance from microwaves during use, this instruction is not specific to clients with pacemakers.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should maintain the affected leg elevated on several pillows to reduce swelling and promote venous return. Elevating the leg helps minimize edema, which can be beneficial for the healing process and overall comfort of the client.
Choice B rationale:
Instructing the client to wiggle the toes once every 4 hours is not necessary and may cause discomfort to the fractured tibia. Toe wiggling does not provide any significant benefit in this context and could potentially disrupt the healing process.
Choice C rationale:
Using a hair dryer to promote drying of the cast is not recommended. Applying heat to the fiberglass cast may alter its integrity and lead to uneven drying, potentially weakening the cast's support.
Choice D rationale:
Applying heat to the client's cast for pain relief is not advisable. Heat may also weaken the cast material and is unlikely to provide effective pain relief for a fractured tibia. Instead, the nurse should follow the prescribed pain management plan and use appropriate pain medications as ordered by the healthcare provider.
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