A client who underwent a mastectomy 24 hours ago is found to have a hematoma in the surgical site, as evidenced by increased swelling and a firm, bluish discoloration. Which of the following actions should the nurse take first?

Notify the healthcare provider about the hematoma and anticipate potential drainage.

Reassure the client that hematomas are common and usually resolve without intervention

Monitor the client for signs of shock, such as hypotension and tachycardia.

Apply a warm compress to the area to promote reabsorption of the blood.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Notifying the healthcare provider is important but the nurse’s first priority is assessing the client’s overall status.
B. Reassurance without assessment ignores the potential seriousness of a hematoma.
C. Monitoring for signs of shock (hypotension, tachycardia) is the priority action because a hematoma can cause significant blood loss leading to hypovolemic shock.
D. Warm compresses are generally not recommended immediately after hematoma formation, as they may increase bleeding or swelling.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:
A. Complex regional pain syndrome presents as chronic, severe pain and sensitivity in a limb, but it is not associated with respiratory symptoms or fever.
B. Avascular necrosis is a gradual condition resulting from loss of blood supply to bone tissue, not an acute emergency with respiratory and systemic signs.
C. Compartment syndrome presents with severe limb pain, pallor, and pulselessness, but does not cause respiratory distress or fever.
D. Fat embolism syndrome (FES) is a serious complication often seen after long bone fractures like femur fractures. Symptoms include chest pain, tachycardia, tachypnea, fever, hypoxia, and thick white sputum. It is a medical emergency requiring immediate intervention.

A. Check the client's pain level B. Assess for bowel sounds and ask the client if she has passed any flatus C. Put the client on a clear liquid diet D. Administer an antiemetic

Correct Answer is B

Explanation

Rationale:
A. While pain assessment is important, nausea and vomiting post-hysterectomy may indicate gastrointestinal issues that need immediate evaluation.
B. Assessing bowel sounds and asking about flatus helps determine if the gastrointestinal tract is functioning properly, which is critical before advancing diet or administering medications. This should be the first action.
C. Changing the diet to clear liquids may be appropriate but only after assessing GI status.
D. Administering an antiemetic can help symptoms but should follow assessment to rule out underlying issues such as ileus or obstruction.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client who underwent a mastectomy 24 hours ago is found to have a hematoma in the surgical site, as evidenced by increased swelling and a firm, bluish discoloration. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is caring for a client who had a hysterectomy and resumed a regular diet earlier in the day. The client is now reporting nausea and has vomited once. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is assessing the neurovascular status of a client who has had a leg cast recently applied. The nurse cannot palpate the client's dorsalis pedis or posterior tibial pulse, and the client's foot is pale. What is the nurse's most appropriate action?

The nurse is providing discharge teaching for a client who developed a pulmonary embolism after total knee surgery. The client has been converted from heparin to sodium warfarin (Coumadin) anticoagulant therapy. What should the nurse teach the client?

The nurse is providing teaching to a client who has breast cancer about the adverse effects of chemotherapy. Which of the following client statements indicates an understanding of the teaching?

A nurse is performing the health history and physical assessment of a client diagnosed with rheumatoid arthritis (RA). What assessment is most consistent with the clinical presentation of RA?

A client who underwent a mastectomy 24 hours ago is found to have a hematoma in the surgical site, as evidenced by increased swelling and a firm, bluish discoloration. Which of the following actions should the nurse take first?

A nurse is caring for a client who has ulcerative colitis and is teaching the client about the common link with Crohn's disease. Which of the following information should the nurse include?

The nurse instructs the client with a right below-the-knee amputation (BKA) to lie on their stomach for at least 30 minutes a day. The client asks the nurse, "Why must I lie on my stomach?" Which statement is the most appropriate for the nurse?

A nurse is reviewing the medical records of a client who has been diagnosed with a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition?