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:
Wound tissue firm to palpation is a false expectation. While firmness can be an indicator of healing in some wounds, it's not a reliable indicator on its own. The appearance and characteristics of the tissue, including granulation tissue, are more significant indicators of healing.
Choice B reason:
Dry brown eschar is a false expectation. Brown eschar is often necrotic tissue that needs to be removed for the wound to heal. Its presence typically suggests a lack of healing progress.
Choice C reason:
Dark red granulation tissue is the correct expectation because it is a sign of healing in a pressure ulcer. Granulation tissue is the new tissue that forms during the healing process, and the dark red color indicates that the tissue is well-vascularized and receiving adequate blood supply, which is essential for healing.
Dark red granulation tissue is a positive sign of wound healing. It indicates that new blood vessels are forming and that the wound is progressing toward the later stages of healing. Granulation tissue is crucial for wound repair and serves as the foundation for new tissue growth.
Choice D reason:
Light yellow exudate is a false expectation. Light yellow exudate is often indicative of infection or non-healing wounds. While some exudate is normal in the healing process, its colour alone doesn't necessarily indicate healing.
Correct Answer is D
Explanation
Choice A Reason:
Increased potassium level is incorrect. Valsartan does not typically cause an increase in potassium levels.
Choice B Reason:
Decreased urinary output is incorrect. Valsartan is not directly associated with changes in urinary output.
Choice C Reason:
Increased heart rate is incorrect. Valsartan generally does not lead to an increased heart rate; it is more likely to help regulate heart rate and reduce strain on the heart.
Choice D Reason:
Decreased blood pressure is correct. Valsartan is an angiotensin II receptor blocker (ARB) commonly used to treat conditions such as heart failure and hypertension. One of its primary effects is to dilate blood vessels and lower blood pressure. Therefore, a decreased blood pressure would indicate that the medication is effective in achieving its therapeutic goal of reducing the workload on the heart and improving circulation.
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