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.

Answer and Explanation

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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Correct Answer is A

Explanation

"Consume 500 fewer calories per day than your estimated calorie needs." Consuming slightly fewer calories than one's estimated calorie needs can help promote weight loss in a healthy and safe way. Planningmeals so that up to 40% of calories come from fats is not typically recommendedwhen trying to lose weight, as too much fat can lead to excess calorie intake. Refined grains should be avoided in favor of whole grains, and it is not recommended to reward oneself with special foods for achieving short-termgoals.

Choice B: Planning meals so that up to 40% of calories come from fat is nottypically recommended when trying to lose weight, as too much fat can lead toexcess calorie intake.

Choice C: Refined grains should be avoided in favor of wholegrains.

Choice D: It is not recommended to reward oneself with special foods forachieving short-term goals.

A. Maintain direct pressure over the site. B. Check whether the bleeding has stopped. C. Obtain a radial pulse. D. Reinforce the dressing over the site.

Correct Answer is A

Explanation

The correct answer is: Choice A: Maintain direct pressure over the site.

Here's the rationale for each choice:

Choice A: Maintain direct pressure over the site (CORRECT) This is the most important initial step in controlling bleeding for any patient, especially one with hemophilia who has a deficiency in clotting factors. Maintaining pressure directly on the wound helps to form a clot and stop the bleeding.
Choice B: Check whether the bleeding has stopped While checking for bleeding cessation is important, it shouldn't be the immediate next step after applying a dressing. Maintaining pressure ensures the dressing remains effective. Once pressure is released, you can assess for continued bleeding.
Choice C: Obtain a radial pulse Assessing the radial pulse is not directly related to managing the bleeding from the laceration. While it's a vital sign, it's not a priority in this situation.
Choice D: Reinforce the dressing over the site While reinforcing the dressing might be necessary later if it becomes saturated with blood, maintaining direct pressure is the crucial first step.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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