A client returns to the surgical unit following a right modified radical mastectomy with dissection of axillary lymph nodes. An appropriate nursing intervention in the postoperative care for the client includes:

changing the surgical dressing when it becomes saturated with drainage.

encouraging the client to obtain permanent breast prosthesis as soon as she is discharged from the hospital.

placing a limb alert bracelet on the right wrist as warning against blood pressure or venipunctures.

teaching the client to use the prescribed patient-controlled analgesia (PCA) every 20 mintues for the best pain relief.

Answer and Explanation

The Correct Answer is C

A.   While it's important to monitor the surgical dressing, changing it too frequently can increase the risk of infection and disrupt healing. Instead, nurses typically assess the dressing regularly and only change it if it's overly saturated or if ordered by a physician. It’s essential to follow specific protocols regarding dressing changes.
B.   A While breast prostheses can be an important part of post-mastectomy care for some clients, it is usually recommended that clients wait until they have fully healed and received counseling regarding their options. Immediate encouragement may be premature, as physical and emotional adjustments take time after surgery.
C.   This is an appropriate intervention. After axillary lymph node dissection, there is a risk of lymphedema in the affected arm. Placing a limb alert bracelet serves as a reminder to healthcare providers to avoid taking blood pressure or performing venipunctures on the affected arm, thus helping prevent complications.
D.   While PCA can be an effective method for managing postoperative pain, the timing and dosage should be based on the specific prescription and the client's individual needs. It’s crucial to educate the client about the PCA device and its use, but the specific interval may vary based on the medication's parameters and the patient's condition.

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Correct Answer is ["14"]

Explanation

154 lbs ÷ 2.2 lbs/kg = 70 kg

20 units/kg * 70 kg = 1400 units

1400 units ÷ 25,000 units/250 mL = 14 mL

Therefore, the nurse will administer 14 mL of Heparin.

A. reduce the risk of blood vessel spasm. B. prevent platelet aggregation. C. dissolve the blood clot. D. prevent infection in the brain.

Correct Answer is C

Explanation

A. While blood vessel spasms can occur after a stroke, t-PA does not directly affect them.
B. Platelet aggregation is the process by which platelets stick together to form a clot. t-PA dissolves clots, but it does not prevent their formation.
C. Tissue plasminogen activator (t-PA) is a medication that can dissolve blood clots. In the case of a thrombotic stroke, a blood clot has blocked blood flow to the brain. By dissolving the clot, t-PA can restore blood flow and limit brain damage.
D. t-PA does not have any direct effect on the risk of infection in the brain.

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A client returns to the surgical unit following a right modified radical mastectomy with dissection of axillary lymph nodes. An appropriate nursing intervention in the postoperative care for the client includes:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is ordered 20 unit/kg IV bolus of Heparin. The patient weighs 154 lbs. Heparin is supplied 25,000 units/250 mL. How many mL will the nurse administer? (round to the nearest whole number)

Correct Answer is ["14"]

Explanation

The nurse is caring for a client who had a thrombotic stroke in the Emergency Department. It has been less than 3 hours since the onset of symptoms. The rationale for using tissue plasminogen activator (t-PA) for this client is to:

Correct Answer is C

Explanation

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