A woman who has undergone a right-sided modified-radical mastectomy returns from surgery. Which nursing intervention would be most appropriate for the nurse to include in the client's plan of care at this time?
Encourage her to turn, cough, and deep breathe at frequent intervals.
Ask the client how she feels about having her breast removed.
Attach a sign above her bed to have BP, IV lines, and lab work on her right arm.
Position her right arm below heart level.
The Correct Answer is A
Choice A: Encourage her to turn, cough, and deep breathe at frequent intervals. This intervention is appropriate for the nurse to include in the client's plan of care at this time because it can help prevent respiratory complications such as atelectasis (collapse of lung tissue) or pneumonia after surgery. Turning, coughing, and deep breathing can help expand the lungs, clear the airways, and improve oxygenation.
Choice B: Ask the client how she feels about having her breast removed. This intervention is not appropriate for the nurse to include in the client's plan of care at this time because it may be too intrusive or insensitive. Asking the client how she feels about having her breast removed may trigger emotional distress or anxiety in the client who has just undergone a major surgery that affects her body image and self-esteem. The nurse should wait until the client is more stable and ready to talk about her feelings and concerns.
Choice C: Attach a sign above her bed to have BP, IV lines, and lab work in her right arm. This intervention is not appropriate for the nurse to include in the client's plan of care at this time because it is incorrect and potentially harmful. Attaching a sign above her bed to have BP, IV lines, and lab work in her right arm may cause injury or infection to the arm that has undergone surgery and lymph node removal. The nurse should attach a sign above her bed to have BP, IV lines, and lab work in her left arm instead.
Choice D: Position her right arm below heart level. This intervention is not appropriate for the nurse to include in the client's plan of care at this time because it is incorrect and potentially harmful. Positioning her right arm below heart level may impair the blood circulation and lymphatic drainage of the arm that has undergone surgery and lymph node removal. The nurse should position her right arm above heart level instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Diarrhea is not the correct answer because it is not a common adverse effect of radiation treatment for breast cancer. Diarrhea is a condition that causes loose, watery, or frequent stools. It can be caused by various factors such as infection, medication, or food intolerance. It is more likely to occur as an adverse effect of radiation treatment for cancers that affect the digestive system, such as colorectal or stomach cancer.
Choice B: Anorexia is not the correct answer because it is not a common adverse effect of radiation treatment for breast cancer. Anorexia is a condition that causes loss of appetite or interest in food. It can be caused by various factors such as depression, stress, or nausea. It is more likely to occur as an adverse effect of chemotherapy or other systemic treatments for cancer that affect the whole body.
Choice C: Fatigue is the correct answer because it is a common adverse effect of radiation treatment for breast cancer. Fatigue is a condition that causes extreme tiredness or exhaustion that is not relieved by rest or sleep. It can be caused by various factors such as anemia, inflammation, or pain. It is a common adverse effect of radiation treatment for any type of cancer, as radiation can damage healthy cells and tissues and affect the body's energy production.
Choice D: Alopecia is not the correct answer because it is not a common adverse effect of radiation treatment for breast cancer. Alopecia is a condition that causes hair loss or thinning on the scalp or other parts of the body. It can be caused by various factors such as genetics, hormones, or infection. It is more likely to occur as an adverse effect of chemotherapy or other systemic treatments for cancer that affect the whole body.
Correct Answer is C
Explanation
Choice A: Limit the intake of fluid. This action is not correct and should not be taught to the client. Limiting the intake of fluid can cause dehydration, urinary tract infection, or kidney stones. The client should drink enough fluid to keep her urine clear and odorless.
Choice B: Void every hour while awake. This action is not correct and should not be taught to the client. Voiding every hour while awake can cause bladder irritation, infection, or overdistension. The client should void when she feels the urge or at least every 3 to 4 hours.
Choice C: Perform Kegel exercises daily. This action is correct and should be taught to the client. Kegel exercises are exercises that strengthen the pelvic floor muscles that support the bladder and urethra. They can help improve bladder control and prevent urinary incontinence. The client should perform Kegel exercises daily by contracting and relaxing the muscles around the vagina and anus as if she is trying to stop urinating or passing gas.
Choice D: Take a laxative every night. This action is not correct and should not be taught to the client. Taking a laxative every night can cause diarrhea, dehydration, electrolyte imbalance, or dependence. The client should avoid constipation by eating a high-fiber diet, drinking plenty of fluids, and exercising regularly.
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