A woman who has undergone a right-sided modified-radical mastectomy returns from surgery. Which nursing intervention would be most appropriate for the nurse to include in the client's plan of care at this time?
Encourage her to turn, cough, and deep breathe at frequent intervals.
Ask the client how she feels about having her breast removed.
Attach a sign above her bed to have BP, IV lines, and lab work on her right arm.
Position her right arm below heart level.
The Correct Answer is A
Choice A: Encourage her to turn, cough, and deep breathe at frequent intervals. This intervention is appropriate for the nurse to include in the client's plan of care at this time because it can help prevent respiratory complications such as atelectasis (collapse of lung tissue) or pneumonia after surgery. Turning, coughing, and deep breathing can help expand the lungs, clear the airways, and improve oxygenation.
Choice B: Ask the client how she feels about having her breast removed. This intervention is not appropriate for the nurse to include in the client's plan of care at this time because it may be too intrusive or insensitive. Asking the client how she feels about having her breast removed may trigger emotional distress or anxiety in the client who has just undergone a major surgery that affects her body image and self-esteem. The nurse should wait until the client is more stable and ready to talk about her feelings and concerns.
Choice C: Attach a sign above her bed to have BP, IV lines, and lab work in her right arm. This intervention is not appropriate for the nurse to include in the client's plan of care at this time because it is incorrect and potentially harmful. Attaching a sign above her bed to have BP, IV lines, and lab work in her right arm may cause injury or infection to the arm that has undergone surgery and lymph node removal. The nurse should attach a sign above her bed to have BP, IV lines, and lab work in her left arm instead.
Choice D: Position her right arm below heart level. This intervention is not appropriate for the nurse to include in the client's plan of care at this time because it is incorrect and potentially harmful. Positioning her right arm below heart level may impair the blood circulation and lymphatic drainage of the arm that has undergone surgery and lymph node removal. The nurse should position her right arm above heart level instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Antiestrogens are not a first-line treatment for endometriosis, as they can cause severe side effects such as bone loss, hot flashes, and vaginal dryness.
Choice B reason: Progestins are a first-line treatment for endometriosis, as they can suppress the growth of endometrial tissue and reduce pain and bleeding.
Choice C reason: Gonadotropin-releasing hormone analogues are a second-line treatment for endometriosis, as they can induce temporary menopause and cause bone loss, hot flashes, and mood changes.
Choice D reason: NSAIDs are not a treatment for endometriosis, as they can only provide symptomatic relief for pain and inflammation.
Correct Answer is B
Explanation
Choice A: Danazol is not the correct answer because it is a drug that can be used to treat fibrocystic breast disease. Danazol is a synthetic hormone that reduces the production of estrogen and progesterone, which are involved in the development of breast cysts.
Choice B: Penicillin is the correct answer because it is a drug that has no effect on fibrocystic breast disease. Penicillin is an antibiotic that is used to treat bacterial infections, such as strep throat or syphilis. It has no role in the management of fibrocystic breast disease.
Choice C: Bromocriptine is not the correct answer because it is a drug that can be used to treat fibrocystic breast disease. Bromocriptine is a dopamine agonist that inhibits the secretion of prolactin, which is a hormone that stimulates breast tissue growth and milk production.
Choice D: Tamoxifen is not the correct answer because it is a drug that can be used to treat fibrocystic breast disease. Tamoxifen is an anti-estrogen that blocks the action of estrogen on breast cells, which can reduce the size and number of breast cysts.
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