Author Question: What comfort measure can only be performed by a nurse, as opposed to an unlicensed assistive ... (Read 107 times)

Starlight

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What comfort measure can only be performed by a nurse, as opposed to an unlicensed assistive personnel (UAP), for a client who returned from a left modified radical mastectomy 4 hours ago?
 
  a. Placing the head of bed at 30 degrees
  b. Elevating the left arm on a pillow
  c. Administering morphine for pain at a 4 on a 0-to-10 scale
  d. Supporting the left arm while initially ambulating the client

Question 2

A client is discharged to home after a modified radical mastectomy with two drainage tubes. Which statement by the client would indicate that further teaching is needed?
 
  a. I am glad that these tubes will fall out at home when I finally shower.
  b. I should measure the drainage each day to make sure it is less than an ounce.
  c. I should be careful how I lie in bed so that I will not kink the tubing.
  d. If there is a foul odor from the drainage, I should contact my doctor.



cascooper22

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Answer to Question 1

ANS: C
Only the nurse is authorized to administer medications, but the UAP could inform the nurse about the rating of pain by the client. The UAP could position the bed to 30 degrees and elevate the client's arm on a pillow to facilitate lymphatic fluid drainage return. The client's arm should be supported while walking at first but then allowed to hang straight by the side. The UAP could support the arm while walking the client.

Answer to Question 2

ANS: A
The drainage tubes (such as a Jackson-Pratt drain) lie just under the skin but need to be removed by the health care professional in about 1 to 3 weeks at an office visit. Drainage should be less than 25 mL in a day's time. The client should be aware of her positioning to prevent kinking of the tubing. A foul odor from the drainage may indicate an infection; the doctor should be contacted immediately.



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cascooper22

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