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.

Answer and Explanation

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.

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Correct Answer is ["0.8"]

Explanation

- To find out how many mL to administer for a medication dose, we need to use this formula: mL = (dose in mg) / (concentration in mg/mL)

- In this formula, the dose in mg is the amount of medication ordered by the provider, and concentration in mg/mL is the strength of medication available in the vial or syringe.

- We plug in the given values into this formula: mL = (30 mg) / (40 mg/mL)

- We simplify and solve this equation: mL = 0.75 mL

- We round off to the nearest tenth: mL = **0.8 mL**

- We add a leading zero if needed: mL = **0.8 mL**

- We do not add a trailing zero: mL = **0.8 mL**

A. Baby oil is an acceptable lubricant. B. Ensure a tight fit of the condom. C. Only use latex condoms. D. Place the condom on an erect penis. E. Store the condoms in a cool dry place.

Correct Answer is ["C","D","E"]

Explanation

Choice A reason: Baby oil is not an acceptable lubricant, as it can damage the condom and reduce its effectiveness. The students should use water-based or silicone-based lubricants instead.

Choice B reason: Ensuring a tight fit of the condom is not advisable, as it can cause discomfort and increase the risk of breakage. The students should leave some space at the tip of the condom to collect semen and prevent spillage.

Choice C reason: Only using latex condoms is correct, as they are more effective than other materials in preventing pregnancy and sexually transmitted infections. The students should avoid using condoms made of natural skin or lambskin, as they are porous and can allow viruses to pass through.

Choice D reason: Placing the condom on an erect penis is correct, as it ensures proper application and prevents slippage. The students should unroll the condom over the entire length of the penis before any sexual contact.

Choice E reason: Storing the condoms in a cool dry place is correct, as it prevents exposure to heat, moisture, sunlight, or sharp objects that can damage the condom. The students should check the expiration date and integrity of the condom before use.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is to receive enoxaparin 30 mg subcutaneously. Available is enoxaparin 40 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.8"]

Explanation

The public health nurse is teaching young adolescents in a sexual health class the proper use of a condom. Which statements made by the students indicate teaching was successful? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

A nurse is caring for a client who is one day postoperative following a left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast?

A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make?

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A nurse is reviewing information about the Health Insurance Portability and Accountability Act (HIPAA) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates a need for further teaching?

A nurse is preparing a client for radiation treatment who is postoperative following a mastectomy. The nurse should inform the client to expect which of the following adverse effects from the treatment?

A nurse is reinforcing teaching about self-care with a client who has pelvic inflammatory disease. The client does not speak English. Which of the following actions by the nurse is appropriate?

A nurse is preparing to administer hydrocortisone 100 mg IM daily to a client. Available as hydrocortisone 250 mg/2 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth number. Use a leading zero if it applies. Do not use a trailing zero.)