A nurse is providing discharge teaching about lymphedema prevention to a client who is 2 days postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include?
Apply lotion to the incisional site twice daily.
Avoid measuring blood pressure on the affected arm.
Apply deodorant under the affected arm daily.
Avoid lifting objects greater than 5.4 kg (12 lb).
The Correct Answer is B
Choice A rationale:
Applying lotion to the incisional site may not be recommended as it could potentially irritate the incision or interfere with wound healing.
Choice B rationale:
Avoiding blood pressure measurements on the affected arm is important to prevent compromising lymphatic flow and potentially exacerbating lymphedema, a common complication after a modified radical mastectomy.
Choice C rationale:
Applying deodorant under the affected arm is discouraged, as it may contain chemicals that could irritate the surgical area.
Choice D rationale:
While lifting heavy objects is generally discouraged after surgery, the specific weight mentioned (5.4 kg or 12 lb) is not consistently supported as a limitation in post- mastectomy care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Clomiphene is used to induce ovulation in women with infertility. Hot flashes are a common side effect of clomiphene due to its impact on hormone levels. Clomiphene is a medication that stimulates ovulation by blocking estrogen receptors in the hypothalamus and pituitary gland. This causes an increase in the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which stimulate the growth and maturation of ovarian follicles. One of the common side effects of clomiphene is hot flashes, which are caused by the sudden drop in estrogen levels. Hot flashes can be mild or severe, and can occur at any time of the day or night. They usually last for a few minutes and can be accompanied by sweating, palpitations, anxiety, or nausea.
Choice B rationale:
Changes in taste are not a typical side effect of clomiphene.
Choice C rationale:
A dry cough is not typically associated with clomiphene.
Choice D rationale:
Migraine with aura is not typically associated with clomiphene.
Correct Answer is B
Explanation
Choice A rationale:
A contraction stress test is not appropriate in this context and would not address the potential risks associated with the client's symptoms.
Choice B rationale:
The elevated blood pressure and upper abdominal pain suggest potential preeclampsia, a serious complication of pregnancy that can lead to significant maternal and fetal risks. Delivery may be indicated to prevent further complications.
Choice C rationale:
Increasing dietary salt intake is not recommended for managing elevated blood pressure in pregnancy.
Choice D rationale:
Administering ferrous sulfate is unrelated to the client's symptoms and concerns.
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