How should the nurse plan to position a client who has just undergone a radical mastectomy?

A High-Fowler's with the arm on the operative side elevated on pillows.

Semi-Fowler's with the arm on the operative side in a dependent position.

High-Fowler's with the arm on the operative side in a dependent position.

Semi-Fowler's with the arm on the operative side elevated on pillows.

Answer and Explanation

The Correct Answer is D

A. A High-Fowler's with the arm on the operative side elevated on pillows: While elevating the arm is important, a high-Fowler's position may cause unnecessary strain on the surgical site and is not recommended for comfort and healing in the immediate postoperative period.

B. Semi-Fowler's with the arm on the operative side in a dependent position: Keeping the arm in a dependent position can increase the risk of swelling and lymphedema, which should be avoided after a mastectomy.

C. High-Fowler's with the arm on the operative side in a dependent position: The high-Fowler's position, combined with keeping the arm in a dependent position, would likely increase swelling and discomfort and is not recommended postoperatively.

D. Semi-Fowler's with the arm on the operative side elevated on pillows: The semi-Fowler's position is ideal for comfort and healing, and elevating the arm helps reduce the risk of lymphedema by encouraging proper drainage and circulation post-surgery. This is the most appropriate position to promote recovery.

Nursing Test Bank

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Correct Answer is ["B","D","E"]

Explanation

A. Initiate IV oxytocin at 6 milliunits/minute: Oxytocin is not necessary as the patient is not in labor. Administering it could increase contractions, which is not needed and may complicate the patient's condition.

B. Place peripheral IV and administer IV lactated Ringers at 125 mL/hour: IV fluids help maintain blood volume and circulation, which is essential for managing pre-eclampsia and preventing complications like stroke or organ failure.

C. Obtain consult for a cesarean delivery: A cesarean delivery is not the immediate priority. Managing pre-eclampsia and stabilizing the patient is the main focus before deciding on delivery options.

D. Administer IV bolus of 5 grams of magnesium sulfate: Magnesium sulfate prevents seizures in pre-eclampsia or eclampsia. The patient’s clonus and hyperreflexia indicate she is at risk, making this a critical intervention.

E. Initiate seizure precautions, limit visitors: The patient is at risk for eclampsia, so seizure precautions are necessary. Limiting visitors helps reduce external stimuli that could trigger a seizure.

F. Administer oxygen 2 L/minute via nasal cannula: Oxygen is not needed unless there are signs of respiratory distress. The focus should be on managing pre-eclampsia and preventing seizures with magnesium sulphate.

A. Rupture of membranes for 16 hours B. Normal spontaneous vaginal birth C. Breastfeeding 7 to 8 times a day for 10 minutes D. Discharge hemoglobin of 9.2 g/dL (92 g/L) E. Shopping yesterday for 5 hours F. Foul-smelling lochia rubra G. Current vital signs

Correct Answer is ["D","E","F","G"]

Explanation

Rationale for Correct Choices:

Foul-smelling lochia rubra: This is a sign of endometritis, a postpartum uterine infection. It requires immediate attention and treatment with antibiotics.
Discharge hemoglobin of 9.2 g/dL (92 g/L): This indicates anemia, likely from postpartum blood loss. It can contribute to fatigue, dizziness, and weakness, requiring further monitoring.
Current vital signs (Temperature 101.2° F, Heart rate 105 beats/minute, Blood pressure 138/72 mm Hg): Fever and tachycardia are signs of infection. These vital signs support the suspicion of a postpartum infection, possibly endometritis or mastitis.
Shopping yesterday for 5 hours: Prolonged activity, especially with anemia, can exacerbate fatigue and dizziness. Also, being away from the baby for 5 hours could contribute to breast engorgement or inadequate milk expression, potentially leading to mastitis.

Rationale for Incorrect Choices:

Rupture of membranes for 16 hours: While it increases infection risk, the client’s symptoms point more directly to mastitis or endometritis, not complications from prolonged rupture.
Normal spontaneous vaginal birth: A normal birth doesn’t typically lead to the current symptoms. Infection is the most likely cause here.
Breastfeeding 7 to 8 times a day for 10 minutes: The breastfeeding frequency isn’t a concern unless there are signs of nipple trauma or improper latch, which aren’t mentioned here.

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Body System	Nurses Notes and Flow Sheet
Respiratory	Respirations 16 breaths/minute Oxygen saturation of 89% Several deep breaths
Integumentary	Episiotomy intact with no redness Pad is saturated with blood 18 gauge IV to left forearm
Circulatory	Heart rate 96 beats/minute Blood pressure 90/62 mm Hg IV infusing at 125 mL/hr
Genital/Urinary	Boggy fundus 1 cm above umbilicus Fundus rotated to the right Voided 200 mL of clear yellow urine

How should the nurse plan to position a client who has just undergone a radical mastectomy?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse reviews the standing prescriptions for laboring mothers and determines the best plan of care. Which intervention(s) would the nurse initiate? Select all that apply.

Correct Answer is ["B","D","E"]

Explanation

Exhibits The nurse reviews the client's history and physical, the nurses' notes, and the flow sheet. Select the findings that will help the nurse determine which is causing the client's symptoms.

Correct Answer is ["D","E","F","G"]

Explanation

Which is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation?

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Exhibits Choose the most likely options for the information missing from the statement by selecting from the list of options provided. The nurse knows that the mastitis in this scenario is most likely caused by dropdownas evidenced bydropdown.

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