A nurse is caring for a client who has breast cancer and is postoperative following a bilateral mastectomy. Which of the following statements indicates the client has an altered body image?

Choice A reason: Discussing the prescription with the provider is critical, as amoxicillin, a penicillin derivative, is contraindicated in clients with penicillin allergies due to risk of anaphylaxis. This ensures patient safety by verifying or correcting the order, aligning with nursing advocacy and safety protocols, making it correct.
Choice B reason: Administering amoxicillin to a client with a penicillin allergy risks severe allergic reactions, including anaphylaxis, violating patient safety principles. Nurses must verify contraindicated orders before administration, making this action dangerous and incorrect in this scenario.
Choice C reason: Placing an incident report is premature, as no error has occurred yet. The nurse’s role is to prevent harm by addressing the contraindicated prescription proactively. This action does not resolve the issue and is inappropriate as the first step, making it incorrect.
Choice D reason: Calling the pharmacist for clarification is less direct than discussing with the provider, who issued the order. While pharmacists can provide guidance, the provider must confirm or change the prescription to ensure safety, making this action secondary and less effective.

Choice A reason: Marking drainage output every 48 hours is too infrequent to accurately assess drainage in a closed wound drainage system. Frequent monitoring (e.g., every shift) is needed to track output, detect complications like excessive bleeding, and ensure system functionality, making this intervention inadequate for assessment.
Choice B reason: Stripping the chest tube vigorously is not recommended, as it can increase intrathoracic pressure, risking tissue damage or bleeding. It does not assess drainage amount but manipulates the tube, potentially causing harm. Assessment requires observing output in the collection chamber, making this action incorrect.
Choice C reason: Maintaining the collection chamber below the client’s chest ensures proper drainage by gravity in a closed wound drainage system, like a chest tube. This position prevents backflow and allows accurate measurement of drainage output in the chamber, essential for assessing fluid loss and detecting complications like hemothorax.
Choice D reason: Adding water to the water seal chamber maintains system function but does not directly assess drainage amount. The water seal prevents air re-entry, not measures output. Assessment involves observing and recording drainage in the collection chamber, making this action irrelevant to the question’s focus.