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 D

Explanation

Choice A rationale

A blood pressure reading of 110/70 mmHg and heart rate of 90 bpm are generally within normal limits or slightly elevated for a post-procedure client. Normal blood pressure is typically below 120/80 mmHg, and a normal heart rate is between 60 and 100 bpm. These parameters alone do not indicate an immediate post-cardiac catheterization complication requiring urgent reporting.

Choice B rationale

Oozing blood from the puncture site, while requiring continued monitoring and potentially manual pressure, is not as immediately critical as active bleeding or signs of hematoma expansion. Small amounts of oozing are sometimes expected due to the invasive nature of the procedure. The nurse should reinforce the dressing and apply direct pressure if needed, but the primary concern is contained bleeding.

Choice C rationale

The client not voiding since returning to recovery warrants assessment for urinary retention, especially if intravenous fluids were administered, but it is not an immediate life-threatening complication post-cardiac catheterization. While monitoring urine output is important for renal function, especially with contrast dye use, it does not typically require immediate reporting to the cardiologist unless accompanied by other signs of renal compromise.

Choice D rationale

Swelling at the insertion site and a cool extremity distal to the puncture are critical findings indicating potential vascular compromise, such as hematoma formation, retroperitoneal bleed, or arterial occlusion. Swelling suggests fluid accumulation, and coolness indicates impaired arterial blood flow, potentially leading to ischemia of the limb. These require immediate intervention to prevent severe limb damage.

A. Review of chest x-ray. B. Assessment of blood pressure. C. Deep palpation of the abdomen. D. Assessing the client's pain.

Correct Answer is B

Explanation

Choice A rationale

A review of chest x-ray is primarily used to assess pulmonary status or thoracic aortic issues. While a client with an AAA may have concurrent cardiopulmonary conditions, it is not the immediate priority for an abdominal aneurysm where rupture risk is a significant concern.

Choice B rationale

Assessment of blood pressure is the priority because uncontrolled hypertension is a major risk factor for abdominal aortic aneurysm expansion and rupture. Monitoring blood pressure allows for timely intervention to reduce arterial wall stress and prevent a life-threatening event. A normal range is 120/80 mm Hg.

Choice C rationale

Deep palpation of the abdomen is contraindicated in a client with a known abdominal aortic aneurysm due to the significant risk of aneurysm rupture. Palpation can increase intra-abdominal pressure or directly stress the weakened aortic wall, potentially leading to a catastrophic hemorrhage.

Choice D rationale

Assessing the client's pain is important for comfort and to identify potential complications, but it is not the immediate priority over monitoring for signs of rupture. While severe abdominal or back pain can indicate an impending rupture, direct physiological parameters like blood pressure are more critical for immediate risk assessment.

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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?

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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?