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Difficulty: MediumBasic Care and Comfort

A practical nurse is caring for a client who returned to the surgical unit 4 hours ago following a right-sided modified radical mastectomy with axillary lymph node dissection. Which actions should the nurse include in the client's basic care and comfort plan? Select all that apply.

  1. Elevate the client's right arm on a pillow to promote fluid drainage.Answer
  2. B
    Position the client in a right lateral side-lying position to splint the incision.
  3. Maintain the head of the bed in a semi-Fowler's position.Answer
  4. D
    Offer sips of water for throat comfort while the client is supine and difficult to arouse.
  5. E
    Tell the client, 'Do not worry about the swelling; everyone feels this way after this surgery.'
  6. Encourage the client to perform gentle finger and wrist exercises on the right side.Answer

Answer

The correct actions are elevating the right arm on a pillow, maintaining the head of the bed in a semi-Fowler's position, and encouraging gentle finger and wrist exercises on the affected side.
Basic care and comfort following a mastectomy with axillary node dissection focuses on preventing lymphedema, maintaining proper body alignment, and promoting safe circulation. Elevating the affected arm on a pillow utilizes gravity to promote lymphatic and venous drainage. A semi-Fowler's position improves respiratory excursion and general comfort while reducing tension on the chest wall incision. Additionally, guiding the client through gentle distal range-of-motion exercises (finger and wrist) enhances circulation and prevents joint stiffness without risking injury to the primary surgical site.

Step-by-Step Solution

1
Analyze the client's specific surgical procedure and recovery needs.
The client had a right-sided mastectomy with axillary lymph node dissection, indicating a high risk for lymphedema and compromised circulation on the right side.
Understanding the anatomical impact of the surgery identifies the need for specialized positioning and mobility precautions.
2
Evaluate the positioning and mobility interventions for safety and comfort.
Elevating the right arm, raising the head of the bed, and performing distal hand exercises are appropriate basic care measures.
These actions promote venous return, reduce dependent edema, and maintain joint mobility without placing undue stress on the surgical incision.
3
Identify contraindicated or unsafe actions in the distractors.
Lying on the operative right side, giving fluids to a groggy supine patient, and using false reassurance are incorrect and potentially harmful.
These actions compromise local tissue circulation, threaten airway safety, and block therapeutic communication.

Key Concept

Post-Mastectomy Basic Care and Positioning
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Topics

Basic Care and Comfort

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