The client has undergone a wedge resection for cancer of the left breast. Which discharge instruction should the nurse teach?

Maintain the left arm in a dependent position.

Teach the client how to cut cuticles

The cancer has been totally removed, and no follow-up therapy will be required.

Don't lift more than five (5) pounds with the left hand until released by the HCP

Answer and Explanation

The Correct Answer is D

Rationale:
A. The affected arm should be elevated, not kept dependent, to reduce swelling and prevent lymphedema.
B. Clients should be taught NOT to cut cuticles to avoid infections, especially after breast surgery.
C. Follow-up therapy (e.g., radiation, chemotherapy) may still be needed depending on pathology results; clients should be advised to continue regular follow-up.
D. Avoiding lifting heavy objects (more than 5 pounds) with the affected arm until cleared by the healthcare provider helps prevent strain and lymphedema. This is important discharge teaching.

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Correct Answer is B

Explanation

Rationale:
A. Rectal temperatures should be avoided in clients with thrombocytopenia due to the risk of mucosal trauma and bleeding.
B. Using a soft toothbrush helps prevent gum injury and bleeding, which is essential in clients with low platelet counts. This is a correct and important safety measure.
C. A straight-edge razor poses a high risk for cuts; an electric razor should be used instead to minimize bleeding risk.
D. There is no need to limit fruit consumption unless the client is also neutropenic, in which case raw or unwashed produce might be restricted. Fruit intake is not a bleeding risk.

A. Encourage the client to ambulate and increase fluid intake to stimulate urination B. Check the client's bladder for distention and notify the healthcare provider if necessary. C. Increase the client's fluid intake and reassess the output in 4 hours. D. Administer the prescribed pain medication and document the findings

Correct Answer is B

Explanation

Rationale:
A. Encouraging ambulation and fluids may help, but the low urine output (oliguria) over 3 hours warrants assessment of bladder distention first to rule out urinary retention.
B. Checking the bladder for distention is the most appropriate immediate action, as urinary retention is a common postoperative complication that can cause pain and reduced output. The healthcare provider should be notified if retention is present.
C. Increasing fluids alone without assessment may delay necessary intervention.
D. Administering pain medication without assessing the cause of decreased output may mask symptoms and delay diagnosis of urinary retention or other complications.

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The client has undergone a wedge resection for cancer of the left breast. Which discharge instruction should the nurse teach?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating a teaching plan for a client who has thrombocytopenia. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is caring for a client who is 24 hours post-hysterectomy. The client is experiencing moderate abdominal pain and is requesting pain medication. The nurse notices the client's urinary output is 45 mL over the past 3 hours. Which of the following is the most appropriate nursing action?

Correct Answer is B

Explanation

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