A nurse is caring for a client who is postoperative following a right radical mastectomy. Which of the following actions should the nurse take to prevent the development of lymphedema?
Obtain blood pressure readings using the client's right arm.
Limit range-of-motion exercises with the affected arm.
Keep both arms below the level of the client's heart.
Use the client's left arm to obtain blood samples.
The Correct Answer is D
The client had a right radical mastectomy, which can lead to lymphedema, a buildup of fluid that can cause swelling in the arm. Using the client's left arm to obtain blood samples can help prevent injury to the affected arm and reduce the risk of lymphedema. Obtaining blood pressure readings with the client's left arm is also recommended. Range-of-motion exercises are important to prevent stiffness, and elevating the affected arm can help reduce swelling.
A: Obtaining blood pressure readings with the client's right arm can cause injury and increase the risk of lymphedema.
B: Limiting range-of-motion exercises can lead to stiffness and may not prevent lymphedema.
C: Keeping both arms below the level of the client's heart can help reduce swelling, but does not directly prevent lymphedema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D, "I should adjust the TENS unit until I feel a tingling sensation." This is an appropriate statement that indicates the client understands how to use the TENS unit. The TENS unit works by sending electrical impulses to the nerves to block pain signals. The client should adjust the unit until they feel a tingling sensation, which is the desired effect.
"The TENS unit administers a continuous dose of pain medication" is not the correct answer because the TENS unit does not administer medication.
"I will need to charge the TENS unit for 2 hours each day" is not the correct answer because the TENS unit is battery operated and does not need to be charged.
"The TENS unit should be applied at least 6 inches from the actual site of my pain" is not the correct answer because the electrodes should be placed directly on the site of the pain.
Correct Answer is A
Explanation
The correct answer is choice A, "I will attend a support group to help me handle difficulties when they occur." This statement indicates that the client is accepting the situation and taking proactive steps to manage any difficulties that may arise. Choice B is incorrect because relying on someone else to empty the bag suggests possible denial or avoidance of the situation. Choice C is incorrect because normal bowel movements after an ileostomy may not happen. Choice D is incorrect because it is not related to acceptance of the ileostomy. Choice B is not correct because it shows possible denial or avoidance of the situation. Choice C is not correct because normal bowel movements may not occur. Choice D is not correct because it is not related to acceptance of the ileostomy.
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