A nurse is providing discharge teaching to a client following a modified left radical mastectomy with a breast expander. Which of the following statements by the client indicates an understanding of the teaching?
“will keep my left arm flexed at the elbow as much as possible"
“will have to wait 2 months before additional saline can be added to my breast expander"
“should expect less than 25 ml of secretions per day in the drainage devices."
“will perform strength-building arm exercises using a 15-pound weight."
The Correct Answer is C
Choice A reason:
"will keep my left arm flexed at the elbow as much as possible": This statement is incorrect because after a mastectomy, it's important to promote full range of motion in the affected arm to prevent complications like contractures and lymphedema.
Choice B reason:
“will have to wait 2 months before additional saline can be added to my breast expander" Typically, the process of adding saline to a breast expander begins much sooner, often within a few weeks after surgery, depending on the individual’s healing progress and the surgeon’s protocol.
Choice C reason:
"should expect less than 25 ml of secretions per day in the drainage devices":After a mastectomy, drainage devices are often placed to prevent fluid accumulation. The client should be aware that once the drainage decreases to less than 25 ml per day, it may be an indication that the drain can be removed. This shows an understanding of what to monitor postoperatively.
Choice D reason:
"will perform strength-building arm exercises using a 15-pound weight": This statement is not appropriate, especially shortly after surgery. Gradual and gentle strength-building exercises are recommended, and using a 15-pound weight could be too strenuous and potentially harmful.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
The client reports being extremely thirsty with a sore throat - This could be due to the presence of the NG tube and suctioning, but it is not as immediately concerning as the change in drainage colour.
Choice B Reason:
The client's abdomen becomes distended and firm - While this could indicate a possible complication, it is not as directly related to the change in drainage colour.
Choice C Reason:
The drainage is bright green in colour with brown faecal material the finding that the drainage from the NG tube is bright green in colour with brown faecal material should be reported to the provider. This change in the colour and appearance of the drainage can be indicative of bilious (greenish-yellow) vomiting, which may suggest an obstruction or another underlying issue. It's important to assess the client's condition and inform the provider about any significant changes in their symptoms.
Choice D Reason:
The amount of drainage is gradually decreasing - Gradually decreasing drainage could be expected as the condition improves, but it's not as alarming as a change in the drainage colour.
Correct Answer is B
Explanation
Choice A Reason:
A raised lesion with a rolled border - This description might be more indicative of basal cell carcinoma, a different type of skin cancer.
Choice B Reason:
An irregular lesion with irregular borders. Melanoma is a type of skin cancer that originates from melanocytes, the cells responsible for producing the pigment melanin. One of the key characteristics of melanoma is the presence of an irregularly shaped lesion with irregular borders. Melanomas often have uneven, jagged, or notched edges that distinguish them from benign moles or lesions.
Choice C Reason:
A reddened lesion with dilated blood vessels - This description might be more indicative of a vascular lesion or hemangioma, which is not a melanoma.
Choice D Reason:
A scaly lesion with a crusted appearance - This description might be more indicative of squamous cell carcinoma, another type of skin cancer.
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