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."

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason:

Loose tracheal secretions are incorrect. While this could lead to airway issues if not managed, it's not as urgent as stridor.

Choice B reason:

Hypoactive bowel sounds are incorrect. Bowel sounds can be affected by anaesthesia and the surgical procedure, but they are not as immediately critical as airway issues.

Choice C reason:

High-pitched sound on inspiration. A high-pitched sound on inspiration, also known as stridor, can indicate a potential issue with the airway or breathing. Stridor can occur due to narrowing or obstruction of the upper airway, which can be particularly concerning after a thyroidectomy. It could suggest edema, bleeding, or damage to the laryngeal nerves, which are critical for vocal cord function and airway control. Stridor could potentially lead to airway compromise, making it a priority to report to the provider for immediate evaluation and intervention.

Choice D reason:

Client report of pain at the incision is incorrect. Pain management is important, but it's not an immediate threat to the client's airway or overall condition.

A. Administer a sedative medication. B. Determine whether the client has an allergy to local anesthetics C. Describe the sensations the client will feel during the procedure. D. Reinforce the importance of lying still during the procedure

Correct Answer is B

Explanation

Choice A Reason:

Administer a sedative medication is incorrect. Administering a sedative can help the client feel more comfortable during the procedure, but ensuring allergy safety comes first.

Choice B Reason:

Determine whether the client has an allergy to local anaesthetics is correct. The priority intervention for the nurse is to determine whether the client has an allergy to local anaesthetics. Local anaesthetics are typically used to numb the area before a thoracentesis, and ensuring the safety of the client is essential. An allergy to local anaesthetics can result in serious adverse reactions, so it's crucial to identify any allergies before proceeding with the procedure.

Choice C Reason:

Describe the sensations the client will feel during the procedure is incorrect. Providing information about the sensations is important for client education and comfort, but verifying allergies is more critical.

Choice D Reason:

Reinforce the importance of lying still during the procedure - Encouraging the client to lie still is important for the procedure's success and client safety, but confirming allergies takes priority.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a partial thyroidectomy. Which of the following findings is the priority for the nurse to report to the provider?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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