Which nursing action should be included in the plan of care for a patient returning to the surgical unit after a left modified radical mastectomy with dissection of axillary lymph nodes?

Post a sign at the bedside warning against venipunctures or blood pressures in the left arm.

Obtain a permanent breast prosthesis before the patient is discharged from the hospital.

Teach the patient to use the ordered patient-controlled analgesia every 10 minutes.

Insist that the patient examine the surgical incision when the initial dressings are removed.

Answer and Explanation

The Correct Answer is A

Choice A rationale: Post-surgery, there's a risk of lymphedema in the affected arm, so avoiding procedures like venipuncture or blood pressure measurements in the left arm helps prevent complications.

Choice B rationale: Obtaining a permanent breast prosthesis is a consideration post- recovery but not an immediate priority upon return to the surgical unit.

Choice C rationale: Patient-controlled analgesia instructions are important but don't specifically address immediate care after mastectomy.

Choice D rationale: Insisting that the patient examine the surgical incision might not be appropriate upon return to the unit, and it's typically done by healthcare professionals during dressing changes.

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Correct Answer is D

Explanation

Choice A rationale: This is not relevant to the current condition of the patient and does not support a diagnosis of renal calculi.

Choice B rationale: This is a sign of upper gastrointestinal bleeding, which can have many causes such as peptic ulcer, gastritis or esophageal varices. It is not related to renal calculi or urinary tract problems.

Choice C rationale: Renal calculi usually causes pain which usually radiates anteriorly to the lower abdomen, groin, labia, testicles or the perineum depending on the location of the stone.

Choice D rationale: This is a sign of hematuria, which is blood in the urine caused by the passage of renal calculi (kidney stones) through the urinary tract. Hematuria can also cause the urine to appear dark or brown in color.

A. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days. B. The human papillomavirus (HPV), which causes condylomata acuminata, can't be transmitted during oral sex. C. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse. D. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.

Correct Answer is D

Explanation

Choice A rationale: Metronidazole is not typically used to treat genital warts caused by HPV.

Choice B rationale: HPV can be transmitted through various forms of sexual contact, including oral sex.

Choice C rationale: Condoms reduce but do not eliminate the risk of HPV transmission. Choice D rationale: Genital warts caused by HPV increase the risk of cervical cancer,

necessitating regular Pap smears for monitoring and early detection.

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Which nursing action should be included in the plan of care for a patient returning to the surgical unit after a left modified radical mastectomy with dissection of axillary lymph nodes?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?

Correct Answer is D

Explanation

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