Nokea
The nurse is caring for the client who had a left modified radical mastectomy (a total mastectomy with axillary node dissection and removal of the lining over the pectoralis major muscle). Which action by the nurse is appropriate?
- A. Have the client elevate the left arm above the head
- B. Ensure that IV access sites are only on the right side
- C. Have the client view the incision site as soon as possible
- D. Initiate left arm strengthening within 24 hours of surgery
Correct Answer: B
Rationale: A. The arm on the operative side should be elevated on a pillow, but not above the head. B. All IV access sites should be located on the nonoperative side to prevent circulatory impairment. C. Having the client look at the incision should be at the client’s readiness, not as soon as possible. D. Only ROM to the lower arm should be carried out for the first few days after surgery, with exercises and ROM to the shoulder after the drains are removed.
You may also like to solve these questions
The client is admitted to the emergency department after a motor-vehicle accident. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first?
- A. Type and crossmatch for red blood cells immediately (STAT).
- B. Initiate an IV with an 18-gauge needle and hang normal saline.
- C. Have the client sign a consent for an exploratory laparotomy.
- D. Notify the significant other of the client’s admission.
Correct Answer: B
Rationale: Profuse bleeding requires immediate IV access with 18-gauge and NS (B) to stabilize hemodynamics. Crossmatch (A), consent (C), and notification (D) follow.
The client’s nephew has just been diagnosed with sickle cell anemia (SCA). The client asks the nurse, 'How did my nephew get this disease?' Which statement would be the best response by the nurse?
- A. Sickle cell anemia is an inherited autosomal recessive disease.'
- B. He was born with it and both his parents were carriers of the disease.'
- C. At this time, the cause of sickle cell anemia is unknown.'
- D. Your sister was exposed to a virus while she was pregnant.'
Correct Answer: A
Rationale: SCA is an autosomal recessive disorder (A), the most precise explanation. Parents as carriers (B) is partial, cause is known (C), and viral exposure (D) is incorrect.
A child who is being treated for leukemia develops stomatitis. Which of the following nursing care measures is essential?
- A. Using dental floss to clean the teeth
- B. Frequent cleaning of the mouth with an astringent mouthwash
- C. Use of an overbed cradle
- D. Swabbing the mouth with moistened cotton swabs
Correct Answer: D
Rationale: Swabbing the mouth with moistened cotton swabs gently cleans the mouth without irritating stomatitis. Flossing or astringent mouthwash may worsen irritation, and an overbed cradle is unrelated.
The client diagnosed with menorrhagia complains to the nurse of feeling listless and tired all the time. Which scientific rationale would explain why these symptoms occur?
- A. The pain associated with the menorrhagia does not allow the client to rest.
- B. The client’s symptoms are unrelated to the diagnosis of menorrhagia.
- C. The client probably has been exposed to a virus that causes chronic fatigue.
- D. Menorrhagia has caused the client to have decreased levels of hemoglobin.
Correct Answer: D
Rationale: Menorrhagia causes blood loss, lowering hemoglobin (D), leading to fatigue/listlessness. Pain (A) is not primary, symptoms are related (B), and viral fatigue (C) is less likely.
The nurse is administering a transfusion of packed red blood cells to a client. Which interventions should the nurse implement? List in order of performance.
- A. Start the transfusion slowly.
- B. Have the client sign a permit.
- C. Assess the IV site for size and patency.
- D. Check the blood with another nurse at the bedside.
- E. Obtain the blood from the laboratory.
Correct Answer: E,C,B,D,A
Rationale: 1. Obtain blood (E): Retrieve from lab. 2. Assess IV site (C): Ensure 18-gauge patency. 3. Sign permit (B): Obtain consent. 4. Check blood (D): Verify with another nurse. 5. Start slowly (A): Infuse at 10–15 mL/hr initially.