Which nursing action should be included in the plan of care for a patient returning to the surgical unit after a left modified radical mastectomy with dissection of axillary lymph nodes?
Post a sign at the bedside warning against venipunctures or blood pressures in the left arm.
Obtain a permanent breast prosthesis before the patient is discharged from the hospital.
Teach the patient to use the ordered patient-controlled analgesia every 10 minutes.
Insist that the patient examine the surgical incision when the initial dressings are removed.
The Correct Answer is A
Choice A rationale: Post-surgery, there's a risk of lymphedema in the affected arm, so avoiding procedures like venipuncture or blood pressure measurements in the left arm helps prevent complications.
Choice B rationale: Obtaining a permanent breast prosthesis is a consideration post- recovery but not an immediate priority upon return to the surgical unit.
Choice C rationale: Patient-controlled analgesia instructions are important but don't specifically address immediate care after mastectomy.
Choice D rationale: Insisting that the patient examine the surgical incision might not be appropriate upon return to the unit, and it's typically done by healthcare professionals during dressing changes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: The Tensilon test involves injecting edrophonium, and in myasthenia gravis, temporary improvement in muscle strength confirms the diagnosis by demonstrating increased acetylcholine activity at the neuromuscular junction.
Choice B rationale: This describes the pathophysiology of myasthenia gravis but doesn’t directly confirm the diagnosis via the Tensilon test.
Choice C rationale: While this may be seen in myasthenia gravis, the Tensilon test specifically aims to observe improved muscle strength after administration.
Choice D rationale: While the presence of these antibodies is a characteristic of myasthenia gravis, the Tensilon test is used to assess the immediate response to the medication for diagnostic confirmation.
Correct Answer is A
Explanation
Choice A rationale: This patient is likely experiencing hyperosmolar hyperglycemic state (HHS). Rapid administration of IV fluids is crucial to correct severe dehydration associated with HHS.
Choice B rationale: Routine insulin therapy and exercise might be components of diabetes management but wouldn't directly address the immediate concern of severe dehydration and high blood glucose.
Choice C rationale: Cardiac monitoring for potassium changes might be necessary but isn't the primary immediate intervention for HHS.
Choice D rationale: Administering a different antibiotic for the UTI is incorrect, because there is no evidence that the current antibiotic is ineffective or causing adverse effects. The UTI may have triggered the HHS, but it is not the main problem that needs to be addressed urgently.
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