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 C
Explanation
Choice A reason: Vomiting can be a sign of a transfusion reaction, but it is not as specific as low back pain for an acute hemolytic reaction.
Choice B reason: Urticaria, or hives, may indicate an allergic reaction but is not specific to an acute hemolytic reaction.
Choice C reason: Low back pain is a classic symptom of an acute hemolytic reaction, which is a serious and potentially life-threatening condition that requires immediate attention.
Choice D reason: Pulmonary congestion may occur in various conditions and is not the most specific indicator of an acute hemolytic reaction.
Correct Answer is C
Explanation
Choice A reason: Petechiae are small red or purple spots caused by bleeding into the skin, typically not directly associated with anemia.
Choice B reason: Glossitis, which is inflammation of the tongue, can be associated with certain types of anemia but is not specifically related to the low hemoglobin level itself.
Choice C reason: Exertional dyspnea, or difficulty breathing upon exertion, is a common symptom of severe anemia due to the reduced oxygen-carrying capacity of the blood.
Choice D reason: Palpitations, or feeling that the heart is racing or fluttering, can occur in severe anemia as the heart attempts to compensate for the lack of oxygen in the blood.
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