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Question

Difficulty: EasyBasic Care and Comfort

An adult client is resting in bed after undergoing a right modified radical mastectomy with axillary lymph node dissection. How should the nurse position the client's right arm to promote optimal comfort and reduce swelling?

  1. Elevated on a pillowAnswer
  2. B
    Extended flat on the mattress beside the body
  3. C
    Positioned dependently below the level of the heart
  4. D
    Secured firmly across the chest with a draw sheet

Answer

Elevated on a pillow
Following a mastectomy with lymph node removal, the lymphatic drainage pathways in the affected arm are significantly compromised. Elevating the arm on a pillow uses gravity to promote lymphatic and venous return. This essential basic care measure prevents lymphedema (tissue swelling), decreases tension on the surgical site, and maximizes client comfort.

Step-by-Step Solution

1
Identify the surgical procedure and its associated risks.
The client had a right mastectomy with axillary lymph node dissection, which disrupts the normal lymphatic pathways and creates a high risk for fluid accumulation (lymphedema) in the right arm.
Understanding the physiological impact of the surgery guides proper postoperative care and positioning.
2
Determine the basic care intervention that mitigates this risk.
Gravity must be used to assist the compromised lymphatic system in draining fluid away from the distal part of the arm back toward the core circulation.
Edema prevention is a fundamental component of basic care and physical comfort for post-mastectomy clients.
3
Select the position that best supports this physiological goal.
Elevating the arm on a pillow achieves the necessary drainage angle while providing soft, supportive comfort.
This is the standard, evidence-based positioning technique for this specific client population.

Key Concept

Post-mastectomy arm positioning to prevent lymphedema
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Topics

Basic Care and Comfort

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