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 B
Explanation
Choice A: "If your sexual partner has no symptoms, no medication is needed." This statement is false and misleading. Chlamydia is a sexually transmitted infection (STI) that can cause serious complications such as pelvic inflammatory disease (PID), infertility, ectopic pregnancy, and chronic pelvic pain if left untreated. Chlamydia can also be passed on to newborns during delivery, causing eye infections or pneumonia. Therefore, it is important that both the client and their sexual partner(s) receive treatment and abstain from sexual activity until they are cured.
Choice B: "This infection is treated with one dose of azithromycin." This statement is true and accurate. Azithromycin is an antibiotic that can effectively treat chlamydia with one oral dose. However, some people may experience side effects such as nausea, vomiting, diarrhea, or abdominal pain after taking azithromycin. Therefore, it is important that the client follows the instructions and completes the treatment as prescribed.
Choice C: "You need to return in 6 months for retesting." This statement is false and unnecessary. Retesting for chlamydia is recommended only if the client has symptoms, has a new or multiple sexual partner(s), or is pregnant. Otherwise, retesting is not required if the client and their partner(s) have completed the treatment and have no further exposure to chlamydia.
Choice D: "You have to avoid sexual relations for 3 days." This statement is false and insufficient. The client should avoid sexual relations until they and their partner(s) have completed the treatment and have no symptoms of chlamydia. This may take longer than 3 days, depending on the type and duration of the treatment. Therefore, it is advisable that the client uses condoms or abstains from sexual activity until they are cured.
Correct Answer is C
Explanation
Choice A: Trichomoniasis is not the correct answer because it does not match the findings of the client. Trichomoniasis is a sexually transmitted infection (STI) caused by a parasite called Trichomonas vaginalis. It can cause symptoms such as yellow-green or gray frothy vaginal discharge, foul odor, itching, burning, or redness of the vulva or vagina.
Choice B: Genital herpes simplex is not the correct answer because it does not match the findings of the client. Genital herpes simplex is an STI caused by a virus called herpes simplex virus (HSV). It can cause symptoms such as painful blisters or ulcers on or around the genitals, fever, headache, or swollen lymph nodes.
Choice C: Candidiasis is the correct answer because it matches the findings of the client. Candidiasis is a fungal infection caused by a yeast called Candida albicans. It can cause symptoms such as thick, white, cottage cheese-like vaginal discharge, intense itching, burning, or soreness of the vulva or vagina, or dyspareunia (painful sexual intercourse).
Choice D: Bacterial vaginosis is not the correct answer because it does not match the findings of the client. Bacterial vaginosis is a condition caused by an imbalance of the normal vaginal flora (the bacteria that live in the vagina). It can cause symptoms such as thin, gray-white or yellow vaginal discharge, fishy odor, itching, or burning of the vulva or vagina.
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