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 ["A","C","E"]
Explanation
Choice A: Sleep disturbances are the correct answer because they are a symptom of a heart attack observed in women. Sleep disturbances are problems that affect the quality or quantity of sleep, such as insomnia, nightmares, or snoring. They can indicate that the heart is not pumping enough blood and oxygen to meet the body's needs during sleep. About 48% of women who have had a heart attack report having sleep disturbances in the weeks before their event.
Choice B: Syncope is not the correct answer because it is not a symptom of a heart attack observed in women. Syncope is a condition that causes a temporary loss of consciousness due to a drop in blood pressure or blood flow to the brain. It can be caused by various factors such as dehydration, medication side effects, or cardiac arrhythmias. However, it is not a common sign of a heart attack in women, and only about 12% of women who have had a heart attack report having syncope before their event.
Choice C: Unusual fatigue is the correct answer because it is a symptom of a heart attack observed in women. Unusual fatigue is a feeling of extreme tiredness or exhaustion that is not relieved by rest or sleep. It can indicate that the heart is not pumping enough blood and oxygen to meet the body's needs during daily activities. About 70% of women who have had a heart attack report having unusual fatigue in the weeks before their event.
Choice D: Extreme hunger is not the correct answer because it is not a symptom of a heart attack observed in women. Extreme hunger is a feeling of intense or excessive appetite or craving for food. It can be caused by various factors such as diabetes, thyroid disorder, or stress. However, it is not a sign of a heart attack in women, and only about 4% of women who have had a heart attack report having extreme hunger before their event.
Choice E: Arm pain is the correct answer because it is a symptom of a heart attack observed in women. Arm pain is a feeling of discomfort or ache in one or both arms, especially the left arm. It can indicate that the heart muscle is not receiving enough blood and oxygen due to a blocked coronary artery. About 42% of women who have had a heart attack report having arm pain before their event.
Correct Answer is A
Explanation
Choice A: Do not apply heat to the area of irradiation. This instruction is correct and should be included in the teaching. Applying heat to the area of irradiation can increase inflammation, pain, or burning sensation on the skin. The client should avoid heat sources such as hot water, heating pads, or sun exposure in the area of irradiation.
Choice B: Use an antibiotic ointment to treat skin breakdown. This instruction is not correct and should not be included in the teaching. Using an antibiotic ointment to treat skin breakdown can cause allergic reactions, infection, or interference with radiation therapy. The client should consult with her provider before using any topical products in the area of irradiation.
Choice C: Lubricate the skin with hypoallergenic lotion. This instruction is not correct and should not be included in the teaching. Lubricating the skin with hypoallergenic lotion can cause irritation, infection, or interference with radiation therapy. The client should avoid applying any lotions, creams, or oils on the area of irradiation unless prescribed by her provider.
Choice D: Do not wash the area of irradiation. This instruction is not correct and should not be included in the teaching. Washing the area of irradiation can help prevent infection, remove dead skin cells, and reduce odor. The client should wash the area of irradiation gently with mild soap and water, pat it dry, and avoid rubbing or scrubbing.
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