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 will have to wait 2 months before additional saline can be added to my breast expander."
"I should expect less than 25 mL of secretions per day in the drainage devices."
"I will keep my left arm flexed at the elbow as much as possible."
"I will perform strength-building arm exercises using a 15-pound weight."
The Correct Answer is B
The client should expect less than 25 mL of secretions per day in the drainage devices before they are removed, usually within 7 to 10 days after surgery. This indicates that the wound is healing and there is no excessive fluid accumulation in the surgical site. The other statements are incorrect and indicate a need for further teaching. The client should not wait 2 months before additional saline can be added to the breast expander, as this may delay the reconstruction process and increase the risk of infection or contracture.
The client should keep the left arm elevated on a pillow and avoid flexing it at the elbow, as this may impair lymphatic drainage and cause edema or pain. The client should perform gentle range-of-motion exercises with the left arm and avoid lifting heavy objects such as a 15-pound weight, as this may strain the incision or cause bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A high calcium level (hypercalcemia) can indicate complications of TPN, such as bone demineralization, renal calculi, or metabolic alkalosis. The nurse should notify the provider of this finding and expect to adjust the TPN formula or administer fluids and diuretics to lower the calcium level. The other options are within normal or expected ranges for a client receiving TPN.
Correct Answer is D
Explanation
A low potassium level (hypokalemia) can increase the risk for digoxin toxicity because it enhances the binding of digoxin to cardiac cells and increases its effects on cardiac contractility and electrical conduction. The nurse should monitor the client's potassium level and administer potassium supplements as prescribed if needed. The other electrolytes are not directly related to digoxin toxicity.
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