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: Upper back pain is not the correct answer because it is not a common finding associated with uterine fibroids. Upper back pain is a feeling of discomfort or ache in the upper part of the back, between the shoulder blades, or below the neck. It can be caused by various factors such as muscle strain, poor posture, or spinal problems. It is not related to the presence or growth of benign tumors in the uterus.
Choice B: Chronic pelvic pain is the correct answer because it is a common finding associated with uterine fibroids. Chronic pelvic pain is a feeling of discomfort or ache in the lower abdomen or pelvis that lasts for more than six months. It can be caused by various factors such as endometriosis, ovarian cysts, or infection. It is also related to the presence or growth of benign tumors in the uterus, which can press on nerves, blood vessels, or organs and cause inflammation, bleeding, or scarring.
Choice C: Amenorrhea is not the correct answer because it is not a common finding associated with uterine fibroids. Amenorrhea is a condition that causes the absence of menstrual periods for more than three months in a woman who is not pregnant, breastfeeding, or menopausal. It can be caused by various factors such as hormonal imbalance, stress, or weight loss. It is not related to the presence or growth of benign tumors in the uterus, which can cause heavy or irregular menstrual bleeding instead.
Choice D: Diarrhea is not the correct answer because it is not a common finding associated with uterine fibroids. Diarrhea is a condition that causes loose, watery, or frequent stools. It can be caused by various factors such as infection, medication, or food intolerance. It is not related to the presence or growth of benign tumors in the uterus, which can cause constipation or bloating instead.
Correct Answer is A
Explanation
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.
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