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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale: Gloves should be worn during direct contact with the client's skin. This is a standard precaution that applies to all clients, but especially to those with infectious diseases that can be transmitted through contact. Secondary syphilis is highly contagious and can be spread through direct contact with the skin lesions or mucous

membranes of an infected person.

Choice B rationale: This is incorrect because secondary syphilis requires more than standard precautions to prevent transmission.

Choice C rationale: This is incorrect because handwashing is a basic component of standard precautions and is not sufficient to prevent the spread of syphilis.

Choice D rationale: This is incorrect because a mask is not necessary for contact precautions, unless the client has respiratory symptoms or is undergoing aerosol- generating procedures.

A. Creatinine, 0.9 mg/dL B. White blood cell count, 11,500 mm" C. BUN 26 mg/dL. D. Reports of pain increasing while coughing E. Potassium 3.3 mEq/L F. Nausea and vomiting

Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale: This is a normal value, indicating normal renal function. The client does not have any signs of kidney damage or impairment.

Choice B rationale: This is an elevated value, indicating an infection or inflammation in the body. Acute appendicitis is a common cause of increased white blood cells, as the appendix becomes inflamed and infected. This finding requires immediate follow-up to monitor the client's condition and prevent complications such as perforation or peritonitis.

Choice C rationale: This is a high value, indicating impaired renal function or dehydration. The client may have decreased urine output due to vomiting and fluid loss, or may have underlying kidney problems. This finding requires immediate follow-up to assess the client's hydration status and renal function, and to provide appropriate fluid and electrolyte replacement.

Choice D rationale: This is a sign of peritoneal irritation, which may indicate that the appendix has ruptured or is close to rupturing. This is a medical emergency that requires immediate surgical intervention to remove the appendix and prevent sepsis and shock.

Choice E rationale: This is a low value, indicating hypokalemia or low potassium levels in the blood. The client may have lost potassium due to vomiting and fluid loss, or may have underlying electrolyte imbalances. This finding requires immediate follow-up to assess the client's cardiac function and muscle strength, and to provide appropriate potassium supplementation.

Choice F rationale: These are common symptoms of acute appendicitis, as the inflammation and infection of the appendix cause irritation of the gastrointestinal tract. These symptoms do not require immediate follow-up, but they should be managed with antiemetics and fluids to prevent dehydration and electrolyte imbalances.

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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?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with multiple traumas after a motor vehicle collision. The nurse learns that the client has secondary syphilis. What precaution should the nurse implement?

Correct Answer is A

Explanation

The nurse is caring for a client who presents with acute appendicitis: Exhibits Select all that apply?

Correct Answer is ["B","C","D","E"]

Explanation

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