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 B
Explanation
Choice A reason: Tumor in situ refers to a tumor that has not invaded surrounding tissues, which is not indicative of stage IV cancer.
Choice B reason: Stage IV cancer is characterized by distant metastasis, meaning the cancer has spread to other sites away from the primary location.
Choice C reason: While the spread into nearby tissues indicates progression, it does not necessarily mean stage IV unless there is distant metastasis.
Choice D reason: The presence of no abnormal cells would not be consistent with any stage of cancer.
Correct Answer is D
Explanation
Choice A reason: Legs in adduction can increase the risk of dislocation after hip replacement surgery.
Choice B reason: Flexing the hip more than 90 degrees can also increase the risk of dislocation.
Choice C reason: Internal rotation of the leg can lead to dislocation of the new hip joint.
Choice D reason: Maintaining the legs in abduction helps to stabilize the hip and prevent dislocation.
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