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Zorluk: OrtaBasic Care and Comfort

A nurse is establishing a plan of care for an older adult client who is recovering from a right-sided modified radical mastectomy with axillary lymph node dissection. Which nursing intervention best addresses the client's basic care and comfort needs while preventing complications?

  1. A
    Turn the client onto the right side-lying position every two hours to facilitate drainage from the surgical site.
  2. B
    Delegate the evaluation of the surgical dressing and right arm capillary refill to the unlicensed assistive personnel (UAP).
  3. Support the client's right arm on pillows to maintain elevation slightly above the level of the heart.Cevap
  4. D
    Secure the client's right arm with a soft wrist restraint immediately if they become disoriented to prevent disruption of the surgical site.

Cevap

The most appropriate intervention is to support the client's affected arm on pillows to keep it elevated above the level of the heart.
Elevating the affected arm on pillows slightly above the level of the heart utilizes gravity to promote lymphatic and venous drainage. This essential basic care measure prevents lymphedema, reduces postoperative edema, and minimizes pain in the affected extremity, promoting overall comfort.

Adım Adım Çözüm

1
Analyze the client's postoperative status following a mastectomy with axillary lymph node dissection.
Recognize that the surgical removal of axillary lymph nodes places the client at a high risk for lymphedema and painful swelling in the right arm.
Understanding the anatomical and physiological alterations is necessary to plan safe and effective comfort care.
2
Evaluate the proposed nursing interventions against safety guidelines and evidence-based practice.
Identify that elevating the affected arm is a safe, non-pharmacologic comfort measure that actively prevents a major postoperative complication.
Elevation utilizes gravity to enhance venous and lymphatic return, addressing the root cause of potential swelling.

Anahtar Kavram

Postoperative Basic Care and Comfort
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Konular

Basic Care and Comfort

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