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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: this corresponds with 25 mg which is lower than the prescribed amount.
Choice B rationale: To answer this question, we need to use the formula: volume (mL) = dose (mg) / concentration (mg/mL). We plug in the given values: volume (mL) = 35 mg / 25 mg/mL. We simplify the fraction: volume (mL) = 7/5. We convert the fraction to a
decimal: volume (mL) = 1.4. Therefore, the nurse should administer 1.4 mL of promethazine.
Choice C rationale: this corresponds with 37.5 mg which is too high.
Choice D rationale: this corresponds with 17.5 mg which is too low.
Correct Answer is A
Explanation
Choice A rationale: Cri du chat syndrome involves a high-pitched cry in infants and other distinct physical and developmental features, but it doesn't present with the described symptoms.
Choice B rationale: Klinefelter syndrome, characterized by an extra X chromosome (XXY) in males, typically presents with small testicles, gynecomastia (enlarged breast tissues), sexual dysfunction, and altered body proportions, such as long legs and a shorter trunk, aligning with the client's symptoms.
Choice C rationale: Patau syndrome (Trisomy 13) manifests with severe developmental issues, facial abnormalities, and other physical malformations, but the described symptoms are not typically associated with this syndrome.
Choice D rationale: Turner syndrome involves females with a missing or partially missing X chromosome (45, X), resulting in specific physical features and medical problems not consistent with the described symptoms in a male client.
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