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 D
Explanation
Choice A reason: Fecal impaction typically presents with the inability to pass stool and may not be associated with the absence of bowel sounds.
Choice B reason: Incisional infection is usually indicated by localized redness, warmth, and possible discharge, not necessarily by the absence of bowel sounds or flatus.
Choice C reason: Health care-associated Clostridium difficile often presents with diarrhea, not the absence of bowel sounds or flatus.
Choice D reason: Paralytic ileus is characterized by impaired intestinal motility and transit, absence of the passage of flatus, diminished bowel sounds, abdominal distension, and intestinal dilatation, fitting the symptoms described.
Correct Answer is ["B","C","D","E","F"]
Explanation
Choice A reason: Telling the patient everything will be okay is not an appropriate intervention as it does not address the specific educational needs related to their knowledge deficit.
Choice B reason: Including family members in teaching can provide additional support and help reinforce the information provided to the patient.
Choice C reason: Identifying knowledge deficiencies is essential to tailor the education to the patient's specific needs.
Choice D reason: Providing written and verbal materials can help the patient understand and remember the information about their surgery and care.
Choice E reason: Determining the patient's anxiety levels can help the nurse address any concerns or fears that may affect their learning.
Choice F reason: Documenting patient understanding and teaching provided is important for continuity of care and to ensure that the patient has received and understood the necessary information.
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