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Difficulty: HardBasic Care and Comfort

A practical nurse is caring for a client who is 24 hours postoperative following a left-sided modified radical mastectomy with axillary lymph node dissection. Which of the following interventions should the nurse include in the client's care plan? Select all that apply.

  1. Elevate the client's left arm and hand on a pillow above the level of the heart.Answer
  2. B
    Position the client in a left lateral position to splint the incision and reduce postoperative pain.
  3. Assist the client with performing prescribed gentle hand and wrist range-of-motion exercises on the left side.Answer
  4. D
    Document a heart rate of 118 beats per minute and blood pressure of 92/58 mm Hg as expected postoperative anxiety without reporting.
  5. Elevate the head of the bed to a semi-Fowler's position to promote comfortable lung expansion.Answer
  6. Ensure that a limb alert bracelet is placed on the left arm to restrict venipunctures and blood pressure readings.Answer

Answer

The correct interventions are elevating the left arm, assisting with left hand and wrist exercises, elevating the head of the bed to a semi-Fowler's position, and ensuring a limb alert bracelet is on the left arm.
For a client recovering from a modified radical mastectomy with axillary lymph node dissection, basic care and comfort must focus on preventing lymphedema, promoting lymphatic drainage, and ensuring adequate respiratory function. Elevating the affected arm above the level of the heart facilitates fluid return. Maintaining a semi-Fowler's position promotes comfortable lung expansion and drainage. Assisting with early, gentle hand and wrist exercises prevents contractures and promotes circulation. Placing a limb alert on the affected side is essential to prevent injury and lymphedema from venipunctures or blood pressure cuffs.

Step-by-Step Solution

1
Analyze the client's surgical procedure and associated risks.
The client had a left-sided modified radical mastectomy with axillary lymph node dissection, resulting in a high risk for lymphedema on the left side and a need for specific positioning.
Understanding the anatomical changes determines the correct basic care and comfort measures.
2
Evaluate the positioning and comfort measures provided in the options.
Elevating the affected arm, elevating the head of the bed, and avoiding the operative side promote fluid drainage and respiratory function. Positioning on the left side is contraindicated.
Correct positioning prevents complications like edema and compromised respiratory status.
3
Evaluate the safety and physiological stability measures.
The left arm must be protected from trauma (e.g., blood pressure cuffs, needles). Additionally, borderline vital signs like tachycardia and hypotension must be recognized as potential shock, not ignored.
Preventing limb injury and escalating critical vital signs are essential components of safe physiological care.

Key Concept

Postoperative basic care following a mastectomy with lymph node dissection includes preventing lymphedema, protecting the affected limb, promoting respiratory function, and maintaining vigilance for signs of hypovolemic shock.
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Topics

Basic Care and Comfort

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