A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?
"I should expect less than 25 mL of secretions per day in the drainage devices."
"I will perform strength-building arm exercises using a 15-pound weight."
"I will keep my left arm flexed at the elbow as much as possible."
"I will have to wait 2 months before additional saline can be added to my breast expander."
The Correct Answer is A
A. Less than 25 mL of secretions per day in the drainage devices is an expected finding after surgery. The nurse should instruct the client to monitor the drainage and report if the output exceeds this amount, as it could indicate a complication.
B. Performing strength-building arm exercises using a 15-pound weight is not recommended immediately after surgery. The client should start with gentle range-of-motion exercises and gradually increase the intensity, but heavy weightlifting should be avoided in the early recovery period.
C. Keeping the left arm flexed at the elbow for prolonged periods is not recommended. The client should be encouraged to perform exercises to prevent stiffness and improve mobility in the affected arm, but excessive flexion can lead to contractures.
D. The client may begin the process of saline expansion in the breast expander soon after surgery, typically within a few weeks. Waiting 2 months may be too long, as expansion is often started earlier to avoid complications such as capsular contracture.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While monitoring the client's temperature is important, it is not the highest priority immediately following sedation.
B. The gag reflex is a critical assessment after moderate sedation, especially following procedures like endoscopy, as it ensures that the client can protect their airway and swallow safely. If the gag reflex is not intact, there is a risk of aspiration or airway obstruction.
C. Warmth of extremities is an important sign of circulation, but it is not as critical as the gag reflex after a procedure involving sedation and airway manipulation.
D. Level of pain is important, but it is secondary to ensuring that the client’s airway is protected. Pain management can be addressed once the client's airway and safety are ensured.
Correct Answer is B
Explanation
A. Using an incentive spirometer is important for improving lung function and preventing atelectasis, but it does not directly address abdominal gas pains.
B. Assisting the client with ambulation is the best action to alleviate abdominal gas pains. Walking helps stimulate peristalsis and can promote the passage of gas, reducing discomfort.
C. Low-fiber food is not recommended for managing abdominal gas pains postoperatively. In fact, high-fiber foods can help prevent constipation and promote bowel movement, which is beneficial for relieving gas.
D. Administering pain medication may be appropriate if the client is in significant pain, but addressing the underlying cause of the pain (gas) by encouraging ambulation is more effective for long-term relief.
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