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.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Ankle swelling can be a common symptom of pregnancy and is not necessarily indicative of a complication.
Choice B rationale:
Gums can become more sensitive during pregnancy, leading to bleeding while brushing teeth. This finding is common and not necessarily indicative of a complication.
Choice C rationale:
Constant pain in the middle of the upper abdomen can be a sign of preeclampsia, a serious pregnancy complication that requires prompt medical attention.
Choice D rationale:
Feeling dizzy when lying flat on the back (supine hypotension) can be a common discomfort during pregnancy due to pressure on the vena cava. However, it does not necessarily indicate a complication in this context.
Correct Answer is B
Explanation
Choice A rationale:
Bulging fontanels are a sign of increased intracranial pressure, which is an abnormal finding in newborns. The nurse should assess for other signs of neurological impairment, such as lethargy, irritability, or seizures.
Choice B rationale:
Blue hands and feet, also known as acrocyanosis, are a normal finding in newborns who are 4 hr old. This is due to immature peripheral circulation and should resolve within 24 to 48 hr.
Choice C rationale:
Generalized petechiae are a sign of bleeding disorders, infection, or trauma, which are abnormal findings in newborns. The nurse should assess for other signs of bleeding, such as bruising, hematuria, or melena.
Choice D rationale:
Flaring of the nares is a sign of respiratory distress, which is an abnormal finding in newborns. The nurse should assess for other signs of respiratory distress, such as grunting, retractions, or cyanosis.
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