The nurse is caring for a client following a modified radical mastectomy. Which assessment finding would indicate that the client is experiencing a complication related to this surgery?
A. Sanguineous drainage in the Jackson-Pratt drain
B. Pain at the incisional site
C. Complaints of decreased sensation near the operative site
D. Arm edema on the operative side
Answer: D
Explanation: Arm edema on the operative side (lymphedema) is a complication following mastectomy and can occur immediately postoperatively or may occur months or even years after surgery. The other options are expected occurrences.
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a. Which dosage strength would be best to use? _____ mg caps b. How many capsules will you administer per dosage? _____ cap(s)
A home health client participates in cultural health practices that the nurse feels might be detrimental to his health. In order to remain attentive to cultural sensitivity and provide appropriate cultural nursing care, the nurse should:
A) Try to negotiate with the client by exploring his views and then providing relevant scientific information. B) Validate the client's practices and understand that for this client, it might be beneficial to continue with his preferences. C) Have the client's physician explain the care to the client in a firm but gentle manner. D) Explain the right and wrong of the client's treatment and try to persuade him to follow the scientific perspective.
The nurse is preparing to give a medication to an adolescent client. The nurse prepares to check the wristband, but it is missing. The nurse needs to:
a. ask the adolescent to self-identify b. have a nearby peer identify the client c. compare the adolescent to a picture ID d. wait for the parents to identify the adolescent
The nurse is selecting dressings for a clean abdominal incision that will be allowed to heal by secondary intention. What principles should the nurse use in choosing this dressing?
1. Materials used in dressing this wound should keep the wound bed moist. 2. The dressing should allow good air circulation through the wound. 3. Dressings should be simple as they will be changed at least every 4 hours. 4. Absorbent material to wick exudates away and support drying should be used.