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Difficulty: MediumBasic Care and Comfort

A practical nurse is providing basic care for an older adult client who had a left-sided mastectomy with axillary lymph node dissection 24 hours ago. The client reports aching, a feeling of heaviness, and stiffness in the left arm. Which nonpharmacological action should the nurse take to promote comfort and reduce these symptoms?

  1. A
    Position the client in a left lateral recumbent position to splint the operative site.
  2. Elevate the client's left arm on pillows so it is positioned above the level of the heart.Answer
  3. C
    Maintain the client's left arm in a dependent position alongside the bed to promote arterial perfusion.
  4. D
    Apply a soft wrist restraint to the left arm to prevent accidental trauma to the incision while resting.

Answer

Elevate the client's left arm on pillows so it is positioned above the level of the heart.
After a mastectomy with axillary lymph node dissection, lymphatic drainage is impaired, leading to edema, heaviness, and discomfort. Elevating the affected arm on pillows above the level of the heart promotes gravity-assisted venous and lymphatic return. This effectively reduces swelling and provides comfort without relying on pharmacological interventions.

Step-by-Step Solution

1
Analyze the client's procedure and symptoms.
The client had a left mastectomy with axillary lymph node dissection and is experiencing aching and heaviness in the left arm.
Axillary node removal disrupts normal lymphatic drainage, leading to localized fluid accumulation (lymphedema) and discomfort.
2
Identify the goal of basic care.
The nurse needs a nonpharmacological intervention to reduce swelling and promote comfort in the affected extremity.
Basic comfort measures should directly address the underlying cause of the discomfort, which is fluid pooling.
3
Evaluate the positioning options.
Elevating the arm above the heart uses gravity to drain fluid, whereas dependent positioning or lying on the arm will worsen the swelling.
Proper postoperative positioning is a fundamental nursing responsibility to prevent complications and maximize comfort.

Key Concept

Postoperative Comfort and Lymphedema Prevention
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Topics

Basic Care and Comfort

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