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 A
Explanation
Epoetin alfa is a medication used to stimulate erythropoiesis, the production of red blood cells. An increase in the client's hemoglobin level indicates that the medication has been effective. The normal range of hemoglobin for adult females is 12-16 g/dL and for adult males is 13.5-17.5 g/dL. A hemoglobin level of 11 g/dL is slightly below the normal range, but it is an improvement from a lower level. Choice B, WBC count 9,000/mm3 is unrelated to the medication and is within the normal range. Choice
C, total calcium 10 mg/dL, and choice D, PT 12 seconds, are also unrelated to the medication and are within the normal range.
Choice B (WBC count 9,000/mm3) is not an answer because it is unrelated to the medication and is within the normal range.
Choice C (total calcium 10 mg/dL) is not an answer because it is unrelated to the medication and is within the normal range.
Choice D (PT 12 seconds) is not an answer because it is unrelated to the medication and is within the normal range.
Correct Answer is C
Explanation
The correct answer is choice C, weigh the client before and after the treatment. The nurse should weigh the client before and after the treatment to evaluate the effectiveness of the dialysis, and determine whether the appropriate amount of fluid has been removed. Choice A is incorrect because the dialysate should be warmed prior to infusion, not chilled. Choice B is incorrect because sterile gloves, not clean gloves, are required when handling dialysate bags. Choice D is incorrect because diarrhea is not a common complication of peritoneal dialysis.
Choice A: Chilling the dialysate prior to infusion is incorrect because the dialysate should be warmed prior to infusion, not chilled.
Choice B: Using clean gloves when handling dialysate bags is incorrect because sterile gloves, not clean gloves, are required when handling dialysate bags.
Choice D: Monitoring the client for diarrhea is incorrect because diarrhea is not a common complication of peritoneal dialysis.
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