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 A

Explanation

Choice A rationale: Considering the mechanism of injury, pain severity, tenderness, swelling, and ecchymosis, there is a high suspicion of a fracture. Immobilization is essential to prevent further injury and reduce pain.

Choice B rationale: Contracture is less likely in this acute injury scenario. Acetaminophen might manage pain, but it doesn't address the risk factor.

Choice C rationale: A sprain is less likely given the severity of pain and the mechanism of injury. Raising the leg doesn't address the risk of a suspected fracture.

Choice D rationale: Dislocation doesn't align with the reported symptoms. Applying heat could potentially worsen inflammation.

A. "To end the collection, I must empty my bladder, adding it to the collection." B. "I should keep the urine container cool in a separate refrigerator or cooler." C. "I should not eat any protein when I am collecting urine for this test." D. "I won't save the first urine when the collection time starts."

Correct Answer is C

Explanation

Choice A rationale: This statement is correct; it's important to include the final voided urine in the collection.

Choice B rationale: Proper storage at a cool temperature helps maintain the integrity of the collected urine.

Choice C rationale: Avoiding protein intake during the collection can significantly alter the results of the creatinine clearance test. Eating a regular diet is important to maintain accurate test results.

Choice D rationale: Discarding the first void and starting the collection afterward is a common practice in 24-hour urine collections to ensure a complete sample.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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