The nurse is providing care for a patient who had a mastectomy for breast cancer 2 days ago. What should the nurse include in the daily care?
Empty the drain device every shift.
Minimize use of the affected arm.
Measure the circumference of both arms.
Place the affected arm below the level of the heart.
The Correct Answer is A
Choice A reason: Emptying the drain device every shift is important to prevent infection and accumulation of fluid, which can impede healing.
Choice B reason: Minimizing use of the affected arm is not recommended; rather, gentle exercises to promote circulation and prevent lymphedema are usually encouraged.
Choice C reason: Measuring the circumference of both arms can be part of monitoring for lymphedema, but it is not the priority in immediate post-mastectomy care.
Choice D reason: Placing the affected arm below the level of the heart is not recommended as it can increase swelling; elevation is usually advised.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Unconsciousness is not typically a finding in the early compensatory stage of hypovolemic shock; it may occur in more advanced stages.
Choice B reason: Tachycardia, or rapid heartbeat, is a compensatory mechanism to maintain cardiac output during the early stages of hypovolemic shock.
Choice C reason: Cold clammy skin is a result of peripheral vasoconstriction, which is a compensatory response to maintain blood flow to vital organs.
Choice D reason: Diminished urine output occurs as the body conserves fluid in response to decreased blood volume.
Correct Answer is A
Explanation
Choice A reason: Antiembolism stockings are designed to apply pressure to the lower legs, promoting blood circulation and preventing blood from pooling in the veins, which can lead to venous stasis.
Choice B reason: While antiembolism stockings aid in circulation, they do not replace the need for postoperative leg exercises, which are important for recovery.
Choice C reason: These stockings are not specifically used to prevent varicose veins; their primary purpose is to prevent deep vein thrombosis (DVT) in postoperative patients.
Choice D reason: The stockings are not primarily used for pain reduction; their main function is to improve venous return and prevent DVT.
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