The nurse is providing care for a patient who had a mastectomy for breast cancer 2 days ago. What should the nurse include in the daily care?

Empty the drain device every shift.

Minimize use of the affected arm.

Measure the circumference of both arms.

Place the affected arm below the level of the heart.

Answer and Explanation

The Correct Answer is A

Choice A reason: Emptying the drain device every shift is important to prevent infection and accumulation of fluid, which can impede healing.

Choice B reason: Minimizing use of the affected arm is not recommended; rather, gentle exercises to promote circulation and prevent lymphedema are usually encouraged.

Choice C reason: Measuring the circumference of both arms can be part of monitoring for lymphedema, but it is not the priority in immediate post-mastectomy care.

Choice D reason: Placing the affected arm below the level of the heart is not recommended as it can increase swelling; elevation is usually advised.

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Correct Answer is B

Explanation

Choice A reason: Providing a pillow to brace the incision is a recommended practice to support the incision during coughing or movement.

Choice B reason: Instructing the patient to perform deep coughing every 30 minutes is a standard postoperative care practice to prevent atelectasis.

Choice C reason: Having the patient sit up and lean forward can help with breathing and comfort after surgery.

Choice D reason: Giving pain medication prior to coughing is actually a recommended practice to reduce pain and facilitate effective coughing.

A. Extend the scheduled time, as the client is finally able to discuss important feelings. B. End at the scheduled time, telling the client that he can continue at the next scheduled session. C. Arrange for another nurse to continue the interview. D. Set an extra meeting time to discuss the client's feelings.

Correct Answer is B

Explanation

Choice A reason: Extending the scheduled time could reinforce the client's resistance to discussing feelings until the end of the session, which is not therapeutic.

Choice B reason: Ending at the scheduled time maintains boundaries and structure, which are important in the therapeutic relationship, especially with clients who have personality disorders.

Choice C reason: Arranging for another nurse to continue the interview may disrupt the continuity of care and the therapeutic relationship.

Choice D reason: Setting an extra meeting time could be considered if the client's needs are urgent, but it is not the best option in this scenario as it may reinforce avoidance behaviors.

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The nurse is providing care for a patient who had a mastectomy for breast cancer 2 days ago. What should the nurse include in the daily care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is B

Explanation

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