A nurse in a surgical clinic is providing teaching to a client who is scheduled for a modified radical mastectomy. Which of the following statements by the client indicates an understanding of the teaching?
"I will complete my arm exercises four times a day."
“I will have my drains removed 1 hour prior to going home."
“I can begin to drive 24 hours after surgery."
"I can shower within 48 hours of my surgery.”
The Correct Answer is A
A. "I will complete my arm exercises four times a day.": Performing arm and shoulder exercises after a modified radical mastectomy helps maintain range of motion, prevent stiffness, and reduce the risk of lymphedema. Regular exercises multiple times a day reflect proper understanding of postoperative rehabilitation.
B. “I will have my drains removed 1 hour prior to going home.": Drain removal is based on the volume of drainage and physician assessment, not a set time before discharge. Premature removal can increase the risk of fluid accumulation and infection.
C. “I can begin to drive 24 hours after surgery.": Driving is usually not recommended until the client has regained adequate strength, range of motion, and is off strong pain medications, typically several days postoperatively. Doing so within 24 hours can be unsafe.
D. "I can shower within 48 hours of my surgery.": Showering is usually delayed until drains are in place and the incision is sufficiently healed, often following specific surgeon instructions. Showering too early can disrupt wound healing and increase infection risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "What part of this assignment makes you upset?": This response encourages open communication, allowing the staff nurse to express specific concerns. It demonstrates active listening, validation of feelings, and promotes problem-solving in a professional and supportive manner.
B. "Let's discuss how this affects your performance improvement plan.": This response shifts the focus to evaluation or discipline rather than addressing the immediate concern. It may create defensiveness and does not validate the nurse’s feelings or allow for discussion of the assignment issue.
C. "Why are you talking to me instead of the charge nurse?": This response is dismissive and may discourage the staff nurse from voicing concerns in the future. It does not address the fairness of the assignment or explore potential solutions.
D. "You are not the only one with a heavy assignment today.": Comparing workloads minimizes the nurse’s concerns and can be perceived as unsupportive. It does not facilitate problem-solving or acknowledge the staff nurse’s feelings about the assignment.
Correct Answer is B
Explanation
A. Heart rate 190/min: A normal newborn heart rate ranges from 120 to 160 beats per minute. A heart rate of 190/min is tachycardic and is above the expected range for a healthy newborn.
B. Irregular respirations: Newborns often exhibit irregular respirations with periods of rapid breathing followed by pauses. This pattern is expected in the first few hours after birth and usually does not indicate distress if oxygen saturation is normal.
C. Central cyanosis: Central cyanosis, including blue lips or tongue, is abnormal and may indicate hypoxemia or congenital heart or respiratory issues. Normal newborns may show brief acrocyanosis of hands and feet but not central cyanosis.
D. Temperature of 38.2° C (100.8° F): A normal newborn temperature ranges from 36.5° C to 37.5° C (97.7° F to 99.5° F). A temperature of 38.2° C is elevated and may indicate infection or overheating.
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