Examkin

Question

Difficulty: MediumBasic Care and Comfort

A client is transferred to the surgical unit following a right modified radical mastectomy that included an axillary lymph node dissection. When implementing basic care and comfort measures, which action should the practical nurse take regarding the client's right arm?

  1. A
    Position the client in a right lateral decubitus position to provide pressure and splint the incision.
  2. B
    Apply a soft wrist restraint to the arm to prevent accidental dislodgment of the surgical drains.
  3. Elevate the arm on pillows so it rests consistently above the level of the client's heart.Answer
  4. D
    Delegate the task of performing initial passive range-of-motion exercises on the arm to an unlicensed assistive personnel.

Answer

The practical nurse should elevate the client's right arm on pillows so it rests consistently above the level of the heart.
Elevating the affected arm above the level of the heart promotes venous and lymphatic return through gravity. This basic care intervention is essential for preventing fluid accumulation (lymphedema) and promoting comfort after the removal of axillary lymph nodes.

Step-by-Step Solution

1
Analyze the surgical procedure and its physiological impact on the client.
A mastectomy with axillary lymph node removal disrupts normal lymphatic drainage pathways, creating a high risk for lymphedema in the affected extremity.
Understanding the physiological risk factors dictates the necessary basic care and comfort interventions.
2
Evaluate each nursing action for safety, scope of practice, and therapeutic benefit.
Elevating the arm uses gravity to assist fluid drainage. The other options introduce significant risks: lying on the arm increases swelling, restraints are an unethical first response to protect drains, and delegating initial post-op joint exercises is unsafe.
Basic care must prioritize non-invasive, safe physiological adaptation while adhering to legal delegation guidelines.
3
Select the action that best promotes fluid return and client comfort.
Supporting the affected arm on pillows above heart level is identified as the correct evidence-based intervention.
This specific positioning directly mitigates the risk of edema and enhances post-procedure comfort without compromising circulation.

Key Concept

Basic care and comfort positioning to prevent lymphedema following axillary lymph node dissection.
Estimated Time:1m 15s
Rate this question

Topics

Basic Care and Comfort

More questions from this topic