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 C
Explanation
Choice A rationale:
A three-prong plug attached to the electrical cord of the client's bed is not a safety hazard. It is a standard plug type used in many electrical devices and poses no immediate danger if properly installed.
Choice B rationale:
Inserting a protective cover into an unused outlet is actually a safety measure to prevent electrical accidents. It is not a hazard but a recommended practice.
Choice C rationale:
Plugging an IV pump into an outlet near a sink is a safety hazard. Water and electricity are a dangerous combination, and any spill or leakage around the outlet could lead to electrical shock or damage to the equipment.
Choice D rationale:
Coiling and securing an electrical cord to the floor can be a potential tripping hazard, but it is not as hazardous as having an electrical device near a sink. Tripping hazards can cause falls, while the combination of water and electricity is more likely to cause serious injuries.
Correct Answer is B
Explanation
Choice A rationale:
Increased peristalsis would be a positive sign and not indicative of postoperative paralytic ileus. Increased peristalsis would mean the bowel is functioning well.
Choice B rationale:
Abdominal distension is a classic sign of postoperative paralytic ileus, where the bowel's motility is reduced or absent. This condition can lead to a buildup of gas and fluids, causing the abdomen to become distended.
Choice C rationale:
Proximal high-pitched bowel sounds can be a normal finding after surgery, but they are not indicative of paralytic ileus. They may even be heard as the bowel recovers its motility.
Choice D rationale:
Passing flatus is a positive sign, as it indicates that the bowel is working and the patient is passing gas. This is not indicative of a postoperative paralytic ileus, which is characterized by the absence of bowel movement.
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