Nokea
The nurse is caring for a patient following breast augmentation surgery. Which of the following information should the nurse include in patient teaching?
- A. A drain will be in place for 24 hours after the surgery and then removed.
- B. Temperature will be monitored every 4 hours postoperatively.
- C. A compression dressing will be in place for 5-7 days.
- D. Most women can resume normal activities 1 week postoperative.
Correct Answer: B
Rationale: The patient's temperature should be monitored. Breast augmentation patients have drains in place in the surgical site to prevent hematoma formation and then removed 2 to 3 days after surgery, or when drainage is less than 20 to 30 mL per day. The drainage must be examined for colour and odour to detect postoperative infection or hemorrhage. A compression dressing is not kept in place for 5-7 days, dressings should be changed as necessary with sterile technique and prescribed. Depending on the extent of the operation, most women can resume normal activities within 2 to 3 weeks. Strenuous exercise may not be appropriate until several weeks later.
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The nurse is assessing a patient at the clinic who has metastatic breast cancer and has a new prescription for trastuzumab. Which of the following findings is a reason for the administration of this medication?
- A. Allergic to iodine
- B. HER-2 positive
- C. Immune to tamoxifen
- D. Severely dehydrated
Correct Answer: B
Rationale: For patients who are HER-2 positive, trastuzumab is a monoclonal antibody to HER-2. After the antibody attaches to the antigen, it is taken into the cancer cells and eventually kills them.
The nurse is assessing a male patient and notes bilateral enlargement of the breasts. Which of the following actions should the nurse take first?
- A. Question the patient about any medications being currently used.
- B. Teach the patient about how to palpate the breast tissue for lumps.
- C. Refer the patient for mammography and biopsy of the breast tissue.
- D. Explain that this is a temporary condition due to hormonal changes.
Correct Answer: A
Rationale: The first action should be further assessment. Since gynecomastia is a possible adverse effect of drug therapy, asking about the current drug regimen is appropriate. The other actions may be needed, depending on the data that are obtained with further assessment.
To determine the risk for breast cancer in a patient who has found a small lump in the left breast, which of the following questions is most pertinent for the nurse to ask?
- A. Do you currently smoke cigarettes?
- B. Have you ever had any breast injuries?
- C. At what age did you start having menstrual periods?
- D. Is there any family history of fibroccystic breast changes?
Correct Answer: C
Rationale: Early menarche and late menopause are risk factors for breast cancer because of the prolonged exposure to estrogen that occurs. Cigarette smoking, breast trauma, and fibroccystic breast changes are not associated with increased breast cancer risk.
A patient with stage II breast cancer tells the nurse, 'I need to decide about what type of surgery to have, but I feel so overwhelmed that I cannot make any decisions yet! What23 do you think I should do?' Which of the following responses by the nurse is best?
- A. I would have a lumpectomy, but you need to decide what is best for you.
- B. Tell me what you understand about the surgical options that are available.
- C. It would not be appropriate for me to make the decision about your health.
- D. There is no need to make a decision rapidly, you have time to think about this.
Correct Answer: B
Rationale: This response indicates the nurse's willingness to assist the patient with the decision-making process without imposing the nurse's values or opinions. It is not appropriate to say that it is not the nurse's decision to make as this would close the conversation and indicates that the nurse is not willing to help the patient with the decision about treatment. Because treatment decisions for breast cancer do need to be made relatively quickly, it is not alright to tell the patient that the decision does not need to be made rapidly. Since the nurse's values and situation are not the same as the patient's, imposing the nurse's opinions during this emotionally vulnerable time is not appropriate.
The nurse is caring for a patient who is scheduled for stereotactic core biopsy of the breast. Which of the following information should the nurse include in patient education?
- A. A local anaesthetic will be given before the biopsy specimen is obtained.
- B. You will need to lie flat on your back and lie very still during the biopsy.
- C. A thin needle will be inserted into the lump and aspirated to remove tissue.
- D. You should not have anything to eat or drink for 6 hours before the procedure.
Correct Answer: A
Rationale: A local anaesthetic is given before stereotactic biopsy. NPO status is not needed because no sedative drugs are given. The patient is placed in the prone position. A biopsy gun is used to obtain the specimens.