A client arrives at the medical-surgical unit shortly after undergoing a right-sided modified radical mastectomy. The practical nurse is initiating immediate postoperative care. Which of the following interventions should the nurse include to promote safety, basic care, and comfort? Select all that apply.
- Elevate the client's right arm on a pillow to facilitate lymphatic drainage.Answer
- Place the client in a semi-Fowler's position to promote comfortable breathing.Answer
- Instruct the client to squeeze a soft washcloth or ball with the right hand.Answer
- DPosition the client on the right side to provide counter-pressure against the incision.
- EChange the client's soiled surgical gown before verifying airway patency.
- FExplain the client's surgical procedure to the roommate to foster a supportive environment.
Answer
The correct actions include elevating the right arm on a pillow, placing the client in a semi-Fowler's position, and instructing the client to perform hand-squeezing exercises.
Appropriate basic care following a mastectomy focuses on preventing lymphedema and respiratory complications. Elevating the affected arm uses gravity to encourage lymphatic fluid return. A semi-Fowler's position reduces tension on the surgical site and promotes full lung expansion. Early, gentle hand exercises enhance circulation and prevent muscle contractures without straining the surgical area.
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Key Concept
Post-Mastectomy Basic Care and Positioning