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 C
Explanation
Choice A rationale:
Drainage in the Hemovac is an expected finding postoperatively and is not as urgent as nonreactive pupils.
Choice B rationale:
Periorbital ecchymosis (bruising around the eyes) is not uncommon after a craniotomy and is not as urgent as nonreactive pupils.
Choice C rationale:
Nonreactive pupils can indicate a neurological emergency, such as increased intracranial pressure or potential damage to the cranial nerves. This finding requires immediate attention to prevent further complications.
Choice D rationale:
Hemoglobin level of 11 g/dL is within a normal range and is not a priority concern.
Correct Answer is C
Explanation
Choice A rationale:
Taking a hot bath to relieve muscle spasms might exacerbate symptoms in individuals with multiple sclerosis due to heat sensitivity.
Choice B rationale:
Participating in high-impact exercise daily can be challenging for individuals with multiple sclerosis, who may experience fatigue and mobility issues.
Choice C rationale:
Adequate hydration is essential for individuals with multiple sclerosis to maintain overall health and support neurological function.
Choice D rationale:
Restricting daily intake of dietary fiber is not recommended, as fiber can aid in maintaining bowel regularity for individuals with multiple sclerosis.
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