NCLEX-PN
Nclex PN Questions and Answers Questions
Extract:
Question 1 of 5
A client scheduled for a left mastectomy and axillary lymph node dissection is wearing a wedding band on her left ring finger. The nurse should take which action?
Correct Answer: C
Rationale: In most situations, a wedding band may be taped in place and worn during a surgical procedure. However, if there is a possibility that the client will experience swelling of the hand or fingers, the wedding band should be removed. On admission to a healthcare facility, the client is usually asked to sign a form that releases the agency from responsibility if a client's valuables are lost. After a mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which can result in swelling of the arm and hand on the affected side.
Therefore, the appropriate nursing action is to ask the client to remove the wedding band and explain why. This ensures the client's safety and prevents potential complications. Option A is incorrect because taping the wedding band may not be sufficient if swelling occurs. Option B is incorrect as it does not address the immediate need to remove the wedding band. Option D is incorrect because it fails to provide the client with the necessary information about the potential risks of wearing the wedding band during surgery.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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