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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B, herpes zoster. A 65-year-old client should receive the herpes zoster vaccine, which is recommended for adults over the age of 60 years to prevent shingles. Choice A is incorrect because inactivated polio virus vaccine is recommended for travelers to areas where polio is endemic or epidemic, and for laboratory workers who handle specimens containing poliovirus. Choice C is incorrect because the human papillomavirus vaccine is recommended for females aged 9-26 years and males aged 9-21 years. Choice D is incorrect because the measles, mumps, and rubella vaccine is recommended for individuals born after 1957 who have not had the vaccine or the diseases.
Choice A: Inactivated polio virus vaccine is incorrect because it is recommended for travelers to areas where polio is endemic or epidemic, and for laboratory workers who handle specimens containing poliovirus.
Choice C: Human papillomavirus vaccine is incorrect because it is recommended for females aged 9-26 years and males aged 9-21 years.
Choice D: Measles, mumps, and rubella vaccine is incorrect because it is recommended for individuals born after 1957 who have not had the vaccine or the diseases.
Correct Answer is B
Explanation
The correct answer is choice B, which cleans a blood spill with chlorine bleach. This is an appropriate action for infection control because bleach is an effective disinfectant that can kill most pathogens, including bloodborne viruses such as HIV and hepatitis B and C.
A. Rolling soiled linen with the clean side in it before placing it in the laundry bag is not the correct answer because it can spread pathogens and cause cross-contamination.
Performing hand hygiene with hands at elbow level is not the correct answer because it is not the correct technique for hand hygiene, which involves washing hands with soap and water or using an alcohol-based hand sanitizer.
Instructing a female client to wipe the perineal area from back to front is not the correct answer because it can cause contamination of the urethra and increase the risk of urinary tract infections.
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