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 C

Explanation

A. Warfarin is an anticoagulant used to prevent blood clots. While it may be prescribed for certain patients at risk for stroke, it is not typically the first-line medication for managing TIA or hyperlipidemia. It is more often used in patients with specific types of atrial fibrillation or mechanical heart valves.
B. Simethicone is an anti-foaming agent used to relieve gas and bloating. It does not have any role in managing hyperlipidemia or preventing strokes. Thus, this option is not relevant to the client's condition.
C. Simvastatin is a statin medication used to lower cholesterol levels and reduce the risk of cardiovascular events, including stroke. For a client with hyperlipidemia and a history of TIA, simvastatin would be an appropriate medication to help manage cholesterol and decrease the risk of future ischemic events.
D. Enoxaparin is a low-molecular-weight heparin used for anticoagulation, often in the context of deep vein thrombosis or pulmonary embolism. It may not be the first choice for TIA management. While it has its uses in preventing clot formation, it is not the standard treatment for a patient who has had a TIA.

A. Apply bacitracin liberally to the affected areas B. Request a medical prescription for diphenhydramine or hydroxyzine C. Instruct client to shower with cool water and use a mild soap D. Clip fingernails and encourage the use of prescribed lotions

Correct Answer is ["B","C","D"]

Explanation

A. Bacitracin is an antibiotic ointment typically used to prevent or treat bacterial infections in minor cuts and scrapes. It is not appropriate for treating a pruritic rash associated with GVHD. The rash may not be due to an infection but rather an immune response, so using bacitracin would not address the underlying issue.
B. Diphenhydramine (Benadryl) and hydroxyzine are antihistamines that can help alleviate itching and provide relief from pruritus. Requesting a prescription for one of these medications is an appropriate response to manage the symptoms of GVHD.
C. Showering with cool water can soothe irritated skin and reduce itching. Using mild soap helps to avoid further irritation or dryness that harsher soaps can cause. This intervention supports skin care and helps manage pruritus effectively.
D. Clipping fingernails can help prevent skin damage from scratching, which could lead to secondary infections. Encouraging the use of prescribed lotions can help keep the skin moisturized and alleviate dryness, further addressing the pruritus associated with GVHD.

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Blood Cell	Normal Ranges
Red blood cells (mature, circulating)	Male 4.51-6.01 million/mm3 Female: 4.01-5.51 million/mm3
Hemoglobin	Adult (15-64 yr) Male 14-17.3 g/dL Female 11.7-15.5 g/dL
Hematocrit	42% -52% in males 36% -48% in females
Reticulocytes	0.5% -2.5% of total RBC count
White blood cells (total)	4.5-11.1 103/mm3
Neutrophils	59% Bands 3% Segs-56%
Eosinophils	2.7%
Basophils	0.5%
Lymphocytes	34%
Monocytes	4%
Platelets	150,000-450,000/mm3

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

The client diagnosed with hyperlipidemia has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?

Correct Answer is C

Explanation

The client has developed graft versus host disease (GVHD) during treatment for acute lymphoblastic leukemia (ALL). The client has a generalized pruritic rash on the trunk and the extremities. What nursing measures should the nurse use to address this problem?

Correct Answer is ["B","C","D"]

Explanation

The nurse receives report at 0700 on a client who has 500 mL of IV fluid left in the bag. The IV is running at 125 mL per hour. At what time should the nurse expect to change the bag (military time)?

The rehabilitation nurse determines that the client who has had a hemorrhagic stroke is successfully adapting to functional changes if they:

The client is diagnosed with a transient ischemic attack (TIA) and is prescribed clopidogrel. Which statement would indicate the medication education has been effective for this client? The client states, "Clopidogrel

The nurse is caring for a client that has undergone a modified left radical mastectomy with lymph node removal. Which intervention would assist in preventing lymphedema?

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