A nurse is providing discharge teaching to a client following a modified left mastectomy. Which statements by the client indicate an understanding of the teaching?
"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."
"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."
The Correct Answer is B
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" This is the correct statement. Following a modified radical mastectomy with a breast expander, additional saline is often added gradually to the expander to stretch the skin and muscle for reconstruction. The waiting period between saline additions allows for healing and proper tissue expansion. This statement indicates that the client understands the postoperative care and timeline.
Choice C reason:
"should expect less than 25 ml of secretions per day in the drainage devices": This statement is not accurate because the drainage amount can vary, and 25 ml per day might not be an accurate estimate.
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 B
Explanation
Choice A Reason:
"This finding may indicate possible medication toxicity." - The red-orange colour change in bodily fluids from rifampin is not indicative of medication toxicity.
Choice B Reason:
"This is an expected adverse effect of this medication." Rifampin is an antibiotic commonly used to treat tuberculosis. One of the well-known side effects of rifampin is the discoloration of bodily fluids, including saliva, tears, sweat, and urine, to a red-orange colour. This is a harmless and expected adverse effect of the medication and is not a sign of toxicity or other serious concerns.
Choice C Reason:
"Your provider will prescribe a different medication regimen." - There is no need to change the medication regimen based solely on the colour change of bodily fluids. This is an expected effect of rifampin.
Choice D Reason:
"You will need to increase your fluid intake to resolve this problem." - Increasing fluid intake will not resolve the colour change caused by rifampin. The client should be educated about the benign nature of the side effects instead.
Correct Answer is D
No explanation
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