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 ["0.8"]
Explanation
- To find the amount of mL to administer per dose, we need to use a ratio and proportion method.
- We can set up a proportion as follows: 250 mg/2 mL = 100 mg/x mL
- To solve for x, we cross-multiply and get: 250x = 200
- Then we divide both sides by 250 and get: x = 200/250
- To simplify, we can reduce the fraction by dividing both the numerator and denominator by 50 and get: x = 4/5
- To convert the fraction to a decimal, we divide 4 by 5 and get: x = 0.8
- Therefore, the nurse should administer 0.8 mL of hydrocortisone per dose.
Correct Answer is D
Explanation
Choice A: Growth spurt is not the correct answer because it is not the first event that occurs in female puberty. The growth spurt is a period of rapid increase in height and weight that usually occurs between 10 and 14 years of age in girls. It is influenced by various factors such as genetics, nutrition, and hormones. Growth spurt usually follows the development of breast buds and pubic hair by about 6 to 12 months.
Choice B: Evidence of pubic hair is not the correct answer because it is not the first event that occurs in female puberty. Evidence of pubic hair is the appearance of coarse, curly, and pigmented hair on the pubic area and around the genitals. It usually occurs between 8 and 13 years of age in girls. It is caused by the increased production of androgens (male hormones) by the adrenal glands and ovaries. Evidence of pubic hair usually follows the development of breast buds by about 3 to 6 months.
Choice C: Onset of menses is not the correct answer because it is not the first event that occurs in female puberty. The onset of menses is the beginning of menstrual cycles, which are regular changes in the female reproductive system that prepare the body for pregnancy. It usually occurs between 10 and 15 years of age in girls. It is caused by the maturation of the hypothalamus, pituitary gland, ovaries, and uterus, which regulate the levels of estrogen and progesterone (female hormones). The onset of menses usually follows the development of breast buds and pubic hair by about 2 to 3 years.
Choice D: Development of breast buds is the correct answer because it is the first event that occurs in female puberty. Development of breast buds is the enlargement and elevation of the nipples and areolas (dark circles around the nipples), which indicate the beginning of breast growth. It usually occurs between 8 and 12 years of age in girls. It is caused by the increased production of estrogen (female hormone) by the ovaries, which stimulates the growth of ducts (tubes) and lobules (glands) in the breast tissue. The development of breast buds is also called thelarche or breast stage 2.
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