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 A

Explanation

A. "I will make sure that we respect your right to refuse medications." – This response respects the client's autonomy and reassures them that their rights will be upheld.

B. "You will need to rest so that you can recover from the episode that brought you here." – This statement dismisses the client's concerns rather than addressing them.

C. "Why do you think your provider will prescribe you medications that will make you sleep?" – While open-ended questions can encourage discussion, this does not directly reassure the client about their rights.

D. "It's not your choice to be here, so you have to accept the treatment we plan for you." – This statement is inappropriate and disregards the client's legal rights.

A. Shake both insulin vials for 2 min before withdrawing the doses. B. Administer the mixture within 5 min of preparing it. C. Withdraw the NPH insulin before the regular insulin. D. Inject air into the regular insulin vial before injecting air into the NPH vial.

Correct Answer is B

Explanation

A. Insulin vials should not be shaken because this can create air bubbles, leading to inaccurate dosing. Instead, NPH insulin should be gently rolled between the palms to evenly mix the suspension. Regular insulin does not require mixing.

B. Once regular and NPH insulin are mixed, they should be administered promptly to maintain their stability and effectiveness. Delaying administration may alter insulin absorption, leading to unpredictable glucose control.

C. Regular insulin should be drawn up before NPH insulin to prevent contaminating the clear regular insulin with the cloudy NPH insulin. The correct order is to inject air into the NPH vial first (without withdrawing insulin), then inject air into the regular insulin vial, withdraw the regular insulin, and finally withdraw the NPH insulin.

D. The correct technique is to first inject air into the NPH vial, then inject air into the regular insulin vial. This prevents contamination and maintains sterility. However, when withdrawing insulin, regular insulin is drawn first to prevent mixing of NPH insulin into the regular insulin vial.

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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

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