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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A: A 26-year-old client who has migraine headaches at the start of each menstrual cycle does not have a contraindication for receiving oral contraceptives. Oral contraceptives are pills that contain synthetic hormones (estrogen and progestin) that prevent ovulation and pregnancy. They can also help regulate menstrual cycles and reduce menstrual pain and bleeding. Some women with migraine headaches may benefit from oral contraceptives, especially if their migraines are related to hormonal fluctuations or menstruation. However, oral contraceptives may worsen migraines in some women, especially if they have aura (visual or sensory disturbances) or other risk factors for stroke. Therefore, oral contraceptives should be used with caution and under medical supervision in women with migraine headaches.

Choice B: A 28-year-old client who has a history of pelvic inflammatory disease does not have a contraindication for receiving oral contraceptives. Pelvic inflammatory disease (PID) is an infection of the female reproductive organs (uterus, fallopian tubes, ovaries) that can cause pain, fever, discharge, or infertility. It can be caused by various bacteria, often sexually transmitted ones such as gonorrhea or chlamydia. Oral contraceptives do not protect against STIs or PID, but they may reduce the risk of PID by thickening the cervical mucus and preventing bacteria from entering the uterus. Therefore, oral contraceptives can be used safely in women with a history of PID, but they should also use condoms or other barrier methods to prevent STIs.

Choice C: A 32-year-old client who has benign breast disease does not have a contraindication for receiving oral contraceptives. Benign breast disease (BBD) is a term that refers to various noncancerous conditions that affect the breast tissue, such as cysts, fibroadenomas, or mastitis. They can cause symptoms such as lumps, pain, or tenderness in the breasts. Oral contraceptives do not cause or increase the risk of BBD, but they may improve some symptoms of BBD by stabilizing the hormonal levels and reducing breast tissue sensitivity. Therefore, oral contraceptives can be used safely in women with BBD, but they should also have regular breast exams and mammograms to monitor their breast health.

Choice D: A 38-year-old client who reports smoking one pack of cigarettes every day has a contraindication for receiving oral contraceptives. Smoking is a habit that involves inhaling the smoke of tobacco or other substances that can cause various health problems, such as lung cancer, heart disease, or stroke. Oral contraceptives can increase the risk of these problems, especially in women who are older than 35 years or smoke more than 15 cigarettes per day. Smoking and oral contraceptives can interact and cause blood clots, high blood pressure, or reduced blood flow to the organs. Therefore, oral contraceptives should be avoided or discontinued in women who smoke, and alternative methods of contraception should be used.

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 nurse is reviewing contraception options for four clients. The nurse should identify which of the following clients has a contraindication for receiving oral contraceptives.

Correct Answer is D

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 maternity client is in need of surgery. Which healthcare member is legally responsible for obtaining informed consent for an invasive procedure?

A nurse is assessing a female client and suspects that the client may have endometrial polyps based on which clinical manifestation?

After teaching a group of adolescent girls about female reproductive development, the nurse determines that teaching was successful when the girls state that menarche is defined as a woman's first:

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?

A nurse is caring for a male client who has a new diagnosis of genital herpes (HSV 2). Which of the following findings should the nurse expect?

A nurse is preparing a class discussion on the clinical manifestations of a heart attack observed in women. Which symptoms would the nurse include as key assessment data? Select all that apply.

A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?