A nurse is caring for a client who is 6 hr postoperative following a modified radical mastectomy. The client has a portable wound bulb suction device in place. Which of the following actions should the nurse take?
Maintain a constant, gentle suction on the drainage device.
Place the client in the supine position while resting in bed.
Prepare to remove the drainage tube 24 hr after the procedure.
Notify the provider for drainage of 25 mL in 24 hr.
The Correct Answer is A
A. Maintain a constant, gentle suction on the drainage device: A portable wound bulb suction device is used to remove blood and serous fluid, prevent hematoma or seroma formation, and promote wound healing. Maintaining constant, gentle suction ensures effective drainage and reduces the risk of complications such as infection or fluid accumulation.
B. Place the client in the supine position while resting in bed: After a mastectomy, clients are typically positioned with the head of the bed elevated and the affected arm supported on a pillow to reduce swelling and promote comfort. Supine positioning without support may increase tension on the surgical site and impair drainage.
C. Prepare to remove the drainage tube 24 hr after the procedure: Drainage tubes are usually removed when output is minimal, often 24–48 hours or longer depending on the volume and type of drainage. Removing the tube at a fixed 24-hour mark may be premature and could increase the risk of fluid accumulation.
D. Notify the provider for drainage of 25 mL in 24 hr: Drainage of 25 mL in 24 hours is minimal and typically does not require provider notification. Normal early postoperative drainage is expected, and the nurse should continue routine monitoring and documentation rather than escalate care for this amount.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is A
Explanation
A. Implement firm but flexible boundaries in their relationship: Establishing boundaries helps both the client and adult child adapt to new caregiving roles while maintaining mutual respect and autonomy. Flexibility allows for adjustments as the client’s needs change, reducing role strain and promoting a healthy family dynamic.
B. Encourage authoritative communication from the adult child: While clear communication is important, an authoritative style may be perceived as controlling and can create tension. Collaborative, respectful communication is more effective in supporting role adjustment and maintaining family harmony.
C. Decrease socialization with extended relatives until roles are identified: Limiting social interactions is unnecessary and may increase isolation or stress. Maintaining connections with extended family can provide emotional support and resources during the transition.
D. Minimize open discussion regarding the changes to avoid embarrassment: Avoiding discussion about changes can lead to misunderstandings, unmet needs, and emotional strain. Open, honest communication helps clarify expectations, reduce conflict, and facilitate adjustment to new roles.
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