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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Correct Answer is D
Explanation
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.
Correct Answer is C
Explanation
Clients with a left-sided stroke will have neurological deficits on the right side of the body, including paralysis or weakness. Impaired speech, language, and cognition are also possible. Blood pressure, temperature, and laboratory results may be affected by the stroke, but they are not specific to a left-sided stroke.
Option A, "Blood pressure," is incorrect because it may be affected by the stroke, but it is not specific to a left-sided stroke.
Option B, "Temperature," is incorrect because it may be affected by the stroke, but it is not specific to a left-sided stroke.
Option D, "Laboratory results," is incorrect because they may be affected by the stroke, but they are not specific to a left-sided stroke.
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