Practice Question
A nurse is assessing the axilla of a patient who recently underwent a mastectomy with lymph node removal. Which finding requires the most urgent nursing intervention?
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Correct Answer:
Enlarged, hard, and fixed lymph nodes in the axilla
Rationale:
💠 Hard, fixed lymph nodes are not a normal postoperative finding; they are highly suspicious for local recurrence or metastasis of breast cancer.
💠 This requires the most urgent intervention, as it could indicate progression of the disease rather than a simple postoperative effect.
💠 Mild tenderness, swelling, decreased sensation, or slight redness are common expected findings after a mastectomy and lymph node dissection due to tissue trauma, nerve involvement, or healing.
💠 Early identification of abnormal lymph node changes allows for prompt oncologic evaluation and treatment adjustments.
💠 The nurse’s role is to immediately report this finding to the surgeon or oncologist for further investigation.
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This question is from Health Assessment Exam 2- Examplify which contains 47 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Health Assessment
- Answer Choices: 4