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Difficulty: HardBasic Care and Comfort

A client is recovering on the surgical unit 24 hours after a right-sided modified radical mastectomy with an axillary lymph node dissection. The client has a closed-suction drain in place and reports incisional pain. What actions should the nurse implement to optimize the client's basic care and comfort? Select all that apply.

  1. Elevate the client's right arm on a pillow to promote lymphatic drainage and prevent lymphedema.Answer
  2. Instruct the client to perform finger, wrist, and elbow flexion exercises on the affected side.Answer
  3. Assist the client to a semi-Fowler's position with the back and unaffected side supported by pillows.Answer
  4. D
    Position the client in a right lateral recumbent position to apply direct pressure to the surgical site.
  5. E
    Delegate the evaluation of the drain insertion site and the surrounding skin integrity to the unlicensed assistive personnel.
  6. F
    Apply a soft wrist restraint to the right arm while the client sleeps to prevent accidental removal of the drain.

Answer

The nurse should elevate the affected right arm on a pillow, instruct the client to perform distal arm exercises (finger, wrist, and elbow), and position the client in a semi-Fowler's position.
Elevating the right arm promotes lymphatic and venous drainage to prevent lymphedema. Performing distal exercises (finger, wrist, elbow) maintains joint mobility and enhances circulation without straining the chest wall incision. Assisting the client to a semi-Fowler's position with support on the unaffected side reduces incisional tension, facilitates optimal lung expansion, and enhances overall client comfort.

Step-by-Step Solution

1
Analyze the client's clinical presentation.
The client is in the early post-operative phase following a right mastectomy with lymph node dissection, has a surgical drain, and is experiencing pain.
Understanding the surgical procedure and time frame is essential to determine appropriate positioning, mobility, and safety needs.
2
Evaluate positioning and mobility interventions for basic care.
Elevating the right arm and performing distal joint exercises are indicated to prevent lymphedema and maintain mobility. The semi-Fowler's position reduces incisional tension.
These actions directly promote lymphatic return, prevent contractures, and provide non-pharmacological comfort.
3
Assess the remaining interventions for safety and delegation appropriateness.
Positioning on the operative side, delegating site evaluation to unlicensed assistive personnel, and applying physical restraints are identified as contraindicated actions.
These actions violate principles of post-operative positioning, the scope of practice for delegation, and safe restraint usage guidelines.

Key Concept

Post-Mastectomy Basic Care and Comfort
Estimated Time:2m 0s
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Topics

Basic Care and Comfort

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