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 C
Explanation
Choice A rationale: The patient with type 2 diabetes admitted with pneumonia might not necessarily need insulin therapy to prevent ketoacidosis.
Choice B rationale: Type 2 diabetes doesn't typically involve islet cell antibodies destroying the pancreas's ability to produce insulin.
Choice C rationale: In this scenario, the patient might have enough endogenous insulin to prevent ketosis but could be at risk for hyperosmolar hyperglycemic syndrome due to illness-induced stress.
Choice D rationale: Type 2 diabetes often involves some degree of endogenous insulin secretion, and not all patients require daily insulin injections.
Correct Answer is A
Explanation
Choice A rationale: Cellulitis management typically involves wound care, antibiotics, and monitoring. It's a suitable assignment for a new graduate nurse to begin learning about wound management and diabetic care.
Choice B rationale: Post-operative care for an amputation requires experience in assessing and managing post-surgical complications, which might not be suitable for a new graduate nurse.
Choice C rationale: Diabetic ketoacidosis management involves complex insulin therapy and critical care, which might be overwhelming for a new graduate nurse.
Choice D rationale: While hyperglycemia requires monitoring and intervention, the cause and severity need to be determined before assigning this patient to a new
graduate nurse.
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