The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema?
Her healthcare provider now prescribes a calcium channel blocker for hypertension.
She sustained an insect bite to her left arm yesterday.
She has lost twenty pounds since the surgery.
Her hobby is playing classical music on the piano.
The Correct Answer is B
Choice A rationale: Her healthcare provider prescribing a calcium channel blocker for hypertension is not directly linked to lymphedema.
Choice B rationale: Sustaining an insect bite to her left arm yesterday - Trauma or injury, such as an insect bite, to the affected limb post-mastectomy can increase the risk of
lymphedema.
Choice C rationale: Losing twenty pounds since the surgery might influence overall health but doesn’t specifically relate to lymphedema.
Choice D rationale: Her hobby of playing classical music on the piano is unrelated to the risk of developing lymphedema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: This is not the accurate amount of fluid intake by the patient.
Choice B rationale: This is less than the total fluid intake by the patient.
Choice C rationale: This is less than the total fluid intake by the patient.
Choice D rationale: This is correct.( This is the sum of the intravenous fluid, the water, and the chicken broth, converted to milliliters: 650 + (6 x 30) + (8 x 30) = 1070.)
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale: This is a normal value, indicating normal renal function. The client does not have any signs of kidney damage or impairment.
Choice B rationale: This is an elevated value, indicating an infection or inflammation in the body. Acute appendicitis is a common cause of increased white blood cells, as the appendix becomes inflamed and infected. This finding requires immediate follow-up to monitor the client's condition and prevent complications such as perforation or peritonitis.
Choice C rationale: This is a high value, indicating impaired renal function or dehydration. The client may have decreased urine output due to vomiting and fluid loss, or may have underlying kidney problems. This finding requires immediate follow-up to assess the client's hydration status and renal function, and to provide appropriate fluid and electrolyte replacement.
Choice D rationale: This is a sign of peritoneal irritation, which may indicate that the appendix has ruptured or is close to rupturing. This is a medical emergency that requires immediate surgical intervention to remove the appendix and prevent sepsis and shock.
Choice E rationale: This is a low value, indicating hypokalemia or low potassium levels in the blood. The client may have lost potassium due to vomiting and fluid loss, or may have underlying electrolyte imbalances. This finding requires immediate follow-up to assess the client's cardiac function and muscle strength, and to provide appropriate potassium supplementation.
Choice F rationale: These are common symptoms of acute appendicitis, as the inflammation and infection of the appendix cause irritation of the gastrointestinal tract. These symptoms do not require immediate follow-up, but they should be managed with antiemetics and fluids to prevent dehydration and electrolyte imbalances.
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