A nurse is caring for a client during the first 24 hours post mastectomy.
Which of the following observations made by the nurse should indicate a complication from the mastectomy procedure?

Phantom breast pain occurs at the mastectomy wound site.

There is a combination of numbness and pain around the breast incision.

Lymphedema is observed in the arm on the same side as the mastectomy.

Wound dressing is saturated with blood every two hours.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Phantom breast pain is a neuropathic pain phenomenon that can occur after mastectomy, characterized by sensations of pain, itching, or tingling in the removed breast. While distressing for the client, it is a common neurological sequela and not typically considered an acute surgical complication indicating immediate danger.

Choice B rationale

A combination of numbness and pain around the breast incision is expected post-mastectomy. Numbness results from nerve transection during surgery, while pain is an anticipated consequence of tissue injury and inflammation. These are normal postoperative sensations, managed with analgesia, and do not typically signify a complication.

Choice C rationale

Lymphedema, characterized by swelling in the arm on the same side as the mastectomy, indicates a complication. It results from impaired lymphatic drainage due to lymph node removal or damage during surgery. This can lead to chronic swelling, discomfort, and increased risk of infection, requiring immediate intervention to manage and prevent progression.

Choice D rationale

A wound dressing saturated with blood every two hours indicates excessive bleeding, which is a significant complication post-mastectomy. While some serosanguineous drainage is normal, continuous saturation suggests active hemorrhage or a hematoma, requiring immediate assessment and potential surgical intervention to control the bleeding.

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Correct Answer is ["1.5"]

Explanation

Step 1 is: Calculate the number of tablets needed. 7.5 mg ÷ (5 mg/tablet) = 1.5 tablets.

A. Health care provider orders Coumadin 2.5 mg P.O. to begin today. B. Client's partial thromboplastin time is 70 seconds and the control is 25-40 seconds. C. Client develops petechiae on the arms, legs, and abdomen. D. Client develops slight ecchymosis at the venipuncture site.

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

Explanation

Choice A rationale

The initiation of oral anticoagulant therapy with Coumadin (warfarin) while a client is on a continuous heparin infusion is a standard and appropriate bridging strategy for managing pulmonary embolism. Heparin provides immediate anticoagulation, while warfarin's therapeutic effect has a delayed onset due to its mechanism of inhibiting vitamin K-dependent clotting factors. This coordinated therapy ensures continuous anticoagulation during the transition.

Choice B rationale

A client's partial thromboplastin time (PTT) of 70 seconds, with a control range of 25-40 seconds, indicates a prolonged clotting time. This suggests that the heparin infusion is causing excessive anticoagulation, increasing the risk of bleeding. Heparin's therapeutic effect is monitored by PTT, and a value significantly above the therapeutic range (typically 1.5 to 2.5 times the control) warrants immediate notification of the healthcare provider to adjust the infusion rate.

Choice C rationale

The development of petechiae on the arms, legs, and abdomen indicates spontaneous bleeding into the skin, which is a significant sign of excessive anticoagulation and potential bleeding complications associated with heparin therapy. Petechiae are small, pinpoint hemorrhages resulting from capillary bleeding, signaling that the client's hemostatic mechanisms are compromised. This is a critical finding requiring immediate medical attention.

Choice D rationale

Slight ecchymosis at a venipuncture site is a common and expected localized minor bleeding manifestation following venous access, especially in clients receiving anticoagulation. While monitoring for any bleeding is crucial, slight bruising at the site of needle insertion is generally not indicative of systemic excessive anticoagulation or a severe complication that would necessitate immediate notification of the healthcare provider in the same urgent manner as widespread petechiae or a significantly prolonged PTT.

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A nurse is caring for a client during the first 24 hours post mastectomy. Which of the following observations made by the nurse should indicate a complication from the mastectomy procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is prescribed Coumadin (warfarin) for anticoagulation therapy. The patient's INR (International Normalized Ratio) is 2.5 and the desired range is 2-3. The medication order is for Coumadin 7.5 mg daily at 6 pm and comes in 5 mg tablets. How many tablets should the nurse administer?

Correct Answer is ["1.5"]

Explanation

A nurse is caring for a client diagnosed with a pulmonary embolism that is placed on a continuous heparin infusion. The nurse should notify the health care provider for which of the following findings?

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

Explanation

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A nurse is caring for a client during the first 24 hours post mastectomy.
Which of the following observations made by the nurse should indicate a complication from the mastectomy procedure?