A client is transferred to the medical-surgical unit following a left-sided mastectomy with an axillary lymph node dissection. The licensed practical nurse (LPN) is assisting with basic care and comfort measures. Which actions are appropriate for the LPN to include in the client's care? (Select all that apply.)
- Elevate the client's left arm on pillows to facilitate lymphatic fluid drainage.Answer
- BPosition the client with the left arm resting dependently below the level of the mattress.
- Assist the client into a semi-Fowler's position to minimize tension on the surgical site.Answer
- DAdminister prescribed intravenous (IV) push opioid analgesics prior to performing hygiene care.
- Encourage the client to perform gentle finger and wrist range-of-motion exercises on the left side.Answer
Answer
The appropriate actions for the LPN to take include elevating the client's left arm on pillows, assisting the client into a semi-Fowler's position, and encouraging gentle finger and wrist range-of-motion exercises on the affected side.
The correct interventions prioritize client comfort and physiological safety following a mastectomy. Elevating the affected arm on pillows facilitates lymphatic and venous fluid drainage, thereby preventing lymphedema. Assisting the client into a semi-Fowler's position reduces stretching and tension on the chest wall incision, minimizing pain and promoting optimal lung expansion. Furthermore, supporting the client in performing early, gentle range-of-motion exercises of the distal joints (fingers and wrist) stimulates circulation and maintains muscle tone without putting stress on the surgical site.
Step-by-Step Solution
Key Concept
Postoperative basic care following a mastectomy focuses on promoting lymphatic drainage (arm elevation), minimizing incisional tension (semi-Fowler's position), maintaining mobility (distal joint exercises), and adhering to the LPN scope of practice.