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Zorluk: OrtaBasic Care and Comfort

A nurse is caring for a 74-year-old client who is 24 hours postoperative following a right-sided modified radical mastectomy with axillary lymph node dissection. The client reports mild discomfort and a feeling of heaviness in the right arm. Which of the following nursing actions is most appropriate to promote comfort and prevent complications?

  1. Elevate the client's right arm on a pillow so it rests slightly above the level of the heart.Cevap
  2. B
    Turn and reposition the client onto the right side to splint the surgical incision and reduce pain.
  3. C
    Delegate the initial teaching of postoperative arm and shoulder exercises to the unlicensed assistive personnel (UAP).
  4. D
    Reassure the client that significant extremity swelling and loss of sensation are normal physiological changes of aging.

Cevap

Elevate the client's right arm on a pillow so it rests slightly above the level of the heart.
Elevating the affected arm on a pillow above the level of the heart uses gravity to facilitate lymphatic and venous drainage. This is a primary, non-pharmacologic comfort measure that reduces postoperative edema (lymphedema) and relieves the sensation of heaviness in the extremity following an axillary lymph node dissection.

Adım Adım Çözüm

1
Analyze the client's postoperative status and reported symptoms.
The client is 24 hours post-mastectomy with axillary node dissection and reports arm heaviness, indicating a high risk for lymphedema and fluid accumulation.
Identifying the physiological risks associated with surgical lymphatic removal is essential for selecting appropriate comfort and preventative measures.
2
Evaluate the proposed nursing interventions against safety protocols and delegation guidelines.
Positioning on the operative side is contraindicated, initial teaching cannot be delegated to a UAP, and assuming symptoms are age-related delays necessary care.
Nursing actions must strictly adhere to scope of practice and evidence-based clinical guidelines to prevent client injury.
3
Select the intervention that safely addresses the client's discomfort.
Elevating the affected arm promotes venous and lymphatic return.
Gravity assists in draining fluid from the extremity, reducing localized edema, and relieving the feeling of heaviness without causing harm.

Anahtar Kavram

Post-mastectomy non-pharmacologic comfort and positioning
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Konular

Basic Care and Comfort

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