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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Provision of home care is not part of the immediate postoperative phase described during preoperative teaching.
Choice B reason: The decision for surgery until transfer to surgery is part of the preoperative phase, not the postoperative phase.
Choice C reason: Admission to the Post Anesthesia Care Unit (PACU) until recovery is the correct description of the postoperative phase, where the patient is monitored as they recover from anesthesia.
Choice D reason: Transfer to surgery until transfer to PACU describes the transition from preoperative to intraoperative phases, not the postoperative phase.
Correct Answer is D
Explanation
Choice A reason: Nurse self-awareness is crucial in providing care for individuals with personality disorders to avoid countertransference.
Choice B reason: Trust is a fundamental component of the nurse-client relationship and is necessary for effective care.
Choice C reason: Limit setting is essential for maintaining professional boundaries and providing structure in the therapeutic relationship.
Choice D reason: Vague communication is not therapeutic and can lead to misunderstandings and increased feelings of inferiority, which is not conducive to treatment.
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