A nurse is providing discharge teaching to a client who is 1 day postoperative following a right modified radical mastectomy. Which of the following instructions should the nurse include in the teaching?

Begin ball squeezing exercises.

Avoid using the affected arm for eating.

Use deodorant under the affected arm.

Wear a bra with wire support.

Answer and Explanation

The Correct Answer is A

A. This is the correct answer. Gentle hand exercises, such as ball squeezing, help promote circulation and prevent lymphedema in the affected arm.

B. Avoiding use of the affected arm for eating is incorrect. Gradual movement is encouraged to prevent stiffness and maintain mobility.

C. Using deodorant under the affected arm is not recommended until healing is complete, as it may cause irritation or infection.

D. A bra with wire support should be avoided initially due to discomfort and potential interference with healing.

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Correct Answer is C

Explanation

A. Placing the client in Trendelenburg position is incorrect because this position does not reduce tension on the abdominal wound and may increase intra-abdominal pressure.

B. Reinserting the protruding intestinal tissue is incorrect because this can introduce infection and cause further damage.

C. This is the correct answer. The priority action is to cover the wound with a sterile, saline-moistened dressing to prevent tissue drying and reduce infection risk.

D. Monitoring vital signs is important, but the priority is to protect the exposed abdominal contents.

A. Pour cool water over the client's perineum. B. Turn on the faucets in the client's sink. C. Tell the client to gently stroke her lower abdomen. D. Instruct the client to lean slightly backward.

Correct Answer is B

Explanation

A. Pour cool water over the client's perineum – Warm, not cool, water is more effective in relaxing the urinary sphincter to promote urination.

B. Turn on the faucets in the client's sink – The sound of running water can trigger the urge to urinate through a reflex mechanism, making this the best option.

C. Tell the client to gently stroke her lower abdomen – This is not an effective technique for stimulating urination.

D. Instruct the client to lean slightly backward – Positioning does not significantly influence urination while using a bedpan.

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A nurse is providing discharge teaching to a client who is 1 day postoperative following a right modified radical mastectomy. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following abdominal surgery. The client reports feeling like "something opened up." The nurse peels back the dressing to find separation of the incision with protrusion of intestinal tissue. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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