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 D

Explanation

Choice A: Caffeine is not the correct answer because it does not interact with metronidazole. Caffeine is a stimulant that can increase alertness, energy, and heart rate. However, it has no effect on the effectiveness or side effects of metronidazole.

Choice B: Chocolate is not the correct answer because it does not interact with metronidazole. Chocolate is a food that contains caffeine, sugar, and fat. However, it has no effect on the effectiveness or side effects of metronidazole.

Choice C: Nicotine is not the correct answer because it does not interact with metronidazole. Nicotine is a substance that can be found in tobacco products, such as cigarettes, cigars, or chewing tobacco. However, it has no effect on the effectiveness or side effects of metronidazole.

Choice D: Alcohol is the correct answer because it interacts with metronidazole. Alcohol is a substance that can be found in beverages, such as beer, wine, or liquor. It can cause a severe reaction when combined with metronidazole, resulting in symptoms such as nausea, vomiting, headache, flushing, and palpitations. Therefore, the nurse should instruct the client to avoid alcohol while taking metronidazole.

A. Refusing to look at the dressing or surgical incision B. Asking questions about the information on her postoperative care pamphlet C. Performing arm exercises once or twice a day D. Asking for pain medication every 3 hours

Correct Answer is A

Explanation

Choice A: Refusing to look at the dressing or surgical incision is the correct answer because it is a behavior that may indicate difficulty adjusting to the loss of her breast. Refusing to look at the dressing or surgical incision may reflect denial, avoidance, or fear of facing the reality of the surgery and its consequences. It may also indicate low self-esteem, body image disturbance, or depression. The nurse should assess the client's emotional state and provide support and education.

Choice B: Asking questions about the information on her postoperative care pamphlet is not the correct answer because it is a behavior that may indicate a positive adjustment to the loss of her breast. Asking questions about the information on her postoperative care pamphlet may reflect acceptance, curiosity, or motivation to learn about her condition and treatment. It may also indicate high self-efficacy, coping skills, or optimism. The nurse should encourage the client's involvement and provide clear and accurate information.

Choice C: Performing arm exercises once or twice a day is not the correct answer because it is a behavior that may indicate a positive adjustment to the loss of her breast. Performing arm exercises once or twice a day may reflect compliance, responsibility, or self-care. It may also indicate physical recovery, functional ability, or quality of life. The nurse should reinforce the client's efforts and provide feedback and guidance.

Choice D: Asking for pain medication every 3 hours is not the correct answer because it is a behavior that may indicate a normal response to the loss of her breast. Asking for pain medication every 3 hours may reflect pain management, comfort, or relief. It may also indicate trust, communication, or satisfaction with care. The nurse should assess the client's pain level and provide adequate and timely pain relief.

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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 with trichomoniasis is to receive metronidazole. What should the nurse instruct the client to avoid while taking this drug?

Correct Answer is D

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?

Correct Answer is A

Explanation

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