Author Question: A client has just returned from a right radical mastectomy. Which action by the unlicensed assistive ... (Read 101 times)

mckennatimberlake · **on:** Jun 25, 2018

A client has just returned from a right radical mastectomy. Which action by the unlicensed assistive personnel (UAP) would the nurse consider unsafe?

a. Checking the amount of urine in the urine catheter collection bag
b. Elevating the right arm on a pillow
c. Taking the blood pressure on the right arm
d. Encouraging the client to squeeze a rolled washcloth

Question 2

A 35-year-old woman is diagnosed with stage III breast cancer. She seems to be extremely anxious. What action by the nurse is best?

a. Encourage the client to search the Internet for information tonight.
b. Ask the client if sexuality has been a problem with her partner.
c. Explore the idea of a referral to a breast cancer support group.
d. Assess whether there has been any mental illness in her past.

zoeyesther · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: C
Health care professionals need to avoid the arm on the side of the surgery for blood pressure measurement, injections, or blood draws. Since lymph nodes are removed, lymph drainage would be compromised. The pressure from the blood pressure cuff could promote swelling. Infection could occur with injections and blood draws. Checking urine output, elevation of the affected arm on a pillow, and encouraging beginning exercises are all safe postoperative interventions.

Answer to Question 2

ANS: C
Support for the diagnosis would be best with a referral to a breast cancer support group. The Internet may be a good source of information, but the day of diagnosis would be too soon. The nurse could assess the frequency and satisfaction of sexual relations but should not assume that there is a problem in that area. Assessment of mental illness is not an appropriate action.