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Difficulty: EasyBasic Care and Comfort

A practical nurse is assigned to care for a client who is recovering from a recent right-sided mastectomy. Which of the following positioning techniques should the nurse implement to promote comfort and prevent swelling in the affected arm?

  1. Elevate the right arm on a pillow while the client is in a semi-Fowler's position.Answer
  2. B
    Place the client in a right lateral position with a pillow between the knees.
  3. C
    Position the client flat on their back with the right arm resting beside the body.
  4. D
    Assist the client to a sitting position with the right arm dangling at their side.

Answer

Elevate the right arm on a pillow while the client is in a semi-Fowler's position.
Elevating the affected arm on a pillow while the client is in a semi-Fowler's position uses gravity to promote lymphatic and venous drainage. This basic care measure effectively prevents lymphedema, reduces tissue swelling, and promotes overall comfort for the client following a mastectomy.

Step-by-Step Solution

1
Identify the client's surgical procedure and the associated risks.
The client had a right-sided mastectomy, which puts them at risk for lymphedema (swelling) in the right arm due to the removal of lymph nodes.
Understanding the procedure is essential for determining the appropriate basic care and comfort interventions.
2
Determine the optimal basic care intervention that addresses the identified risk.
Elevating the affected arm above the level of the heart promotes venous and lymphatic drainage, preventing swelling and enhancing overall comfort.
Gravity assists in returning fluid to the central circulation when the extremity is properly elevated.
3
Select the position that best accommodates this intervention without causing additional harm.
A semi-Fowler's position with the right arm supported on a pillow safely achieves the goal without placing pressure on the surgical site.
This position optimizes drainage and avoids direct pressure on the operative side.

Key Concept

Postoperative positioning to prevent lymphedema after a mastectomy
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Topics

Basic Care and Comfort

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