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Question 91 / 1 ptsA nurse providing preoperative care to a client who is scheduled for a left mastectomy and axillary lymph node dissection notes that the client is wearing a wedding band on her left ring finger. The nurse should:Tape the wedding band in place
Ask the client to sign a release to free the hospital of responsibility if the wedding band is lost during surgeryAsk the client whether she would like to remove the wedding band or wear it to surgeryExplain to the client why the wedding band must be removedRationale: In most situations a wedding band may be taped in place and worn during a surgical procedure. However, if the possibility exists 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 asked to sign a form that frees the agency from responsibility if a client s valuable is lost. After mastectomy with axillary lymph node dissection, the client is at risk for lymphedema, which results in swelling of the arm and hand on the affected side. Therefore the appropriate nursing action is to ask the client toremove the wedding band and explain why.Test-Taking Strategy: Use the process of elimination and focus on the data in the question. Eliminate the options that are comparable or alike in that they indicate that theclient may wear the wedding band during the surgical procedure. Next, recall the complications associated with mastectomy, which will direct you to the correct option. Review preoperative procedures for a client s valuables if you had difficulty with this question.Reference: Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 1387). St. Louis: Mosby.Cognitive Ability: ApplyingClient Needs: Safe and Effective Care EnvironmentIntegrated Process: Nursing Process/ImplementationContent Area: Perioperative CareQuestion 101 / 1 ptsA nurse preparing a client to go to the radiology department for a chest x-ray notes that the client is wearing a religious medal on a chain around the neck. The client, a Catholic, expresses a concern about removing the medal. What is the most appropriate action for the nurse to take?