A client arrives at the surgical step-down unit after undergoing a left modified radical mastectomy with axillary node dissection. When planning the client's basic comfort and safety measures for the current shift, which actions should the nurse include? Select all that apply.
- Elevate the client's left arm on a soft cushion.Answer
- BReposition the client to rest directly on the left side to reduce incisional tension.
- Adjust the head of the bed to a forty-five-degree angle.Answer
- Guide the client to use a small pillow against the chest wall while performing deep breathing exercises.Answer
- EMaintain the client in a flat, supine posture to minimize postoperative dizziness.
Answer
The correct actions include elevating the left arm, adjusting the head of the bed to a forty-five-degree angle, and guiding the client to splint the chest wall during deep breathing.
Appropriate basic care for a postoperative mastectomy client focuses on preventing lymphedema, reducing incisional pain, and optimizing respiratory status. Elevating the affected arm uses gravity to drain lymphatic fluid. Placing the client in a semi-Fowler's position allows the diaphragm to drop, improving lung expansion. Splinting the incision with a pillow provides mechanical support, reducing pain during coughing and deep breathing.
Step-by-Step Solution
Key Concept
Basic care and comfort positioning following a mastectomy