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 D
Explanation
Choice A reason: Increased vaginal discharge is a normal and expected outcome of using a pessary, as it helps to lubricate and cleanse the vagina.
Choice B reason: Urinary tract infection is not a common side effect of using a pessary, as it does not interfere with urination or introduce bacteria into the urinary tract.
Choice C reason: Vaginitis is not a common side effect of using a pessary, as it does not cause inflammation or infection of the vagina. However, the client should maintain good hygiene and use vaginal cream or gel as prescribed to prevent irritation.
Choice D reason: Vaginal ulceration is a serious and possible side effect of using a pessary, as it can cause pressure necrosis and erosion of the vaginal mucosa. The client should report any bleeding, pain, or foul-smelling discharge to the provider and have the pessary removed and replaced regularly.
Correct Answer is B
Explanation
Choice A: "Don't worry, I will be with you during the exam." This response is not appropriate because it does not address the client's feelings or concerns. It also may sound dismissive or patronizing to the client, who may have valid reasons to be nervous.
Choice B: "What part of the exam makes you most nervous?" This response is appropriate because it shows empathy and interest in the client's perspective. It also invites the client to express her fears or questions and allows the nurse to provide information and reassurance.
Choice C: "All you need to do is relax." This response is not appropriate because it does not acknowledge the client's feelings or concerns. It also may sound unrealistic or insensitive to the client, who may find it hard to relax in a stressful situation.
Choice D: "A pelvic exam is required if you want birth control pills." This response is not appropriate because it does not address the client's feelings or concerns. It also may sound coercive or threatening to the client, who may feel pressured or intimidated by the requirement.
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