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.

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Correct Answer is D

Explanation

Rationale:
A. Increasing the rate of bladder irrigation without assessing for obstruction may worsen bladder distention or cause trauma.
B. Catheter irrigation may be necessary, but first the nurse should assess for simple causes of obstruction.
C. Notifying the provider is important if initial troubleshooting fails, but immediate assessment comes first.
D. Checking the tubing for kinks or obstruction is the first action to take when the catheter is not draining, as this is a common and easily corrected cause of urinary retention post-TURP.

A. GnHR B. ERB83 C. CA-125 D. BRCA1 gene

Correct Answer is D

Explanation

Rationale:
A. GnRH (Gonadotropin-releasing hormone) testing is related to reproductive hormone regulation, not breast cancer risk assessment.
B. ERBB3 is a gene involved in cell signaling but is not the primary gene tested for inherited breast cancer risk.
C. CA-125 is a tumor marker primarily used to monitor ovarian cancer, not breast cancer risk.
D. BRCA1 gene testing is indicated for clients with a strong family history of breast cancer, especially early-onset cases, to assess inherited risk.

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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?

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A nurse is caring for a client who is 5 hours postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A client is concerned she may be at risk for breast cancer because she has several relatives, including her mother, diagnosed with it. Her mother died of breast cancer at age 38. Which of the following tests should the nurse anticipate will be done to assess this client's risk?

Correct Answer is D

Explanation

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