A nurse is providing postoperative care for a client who has undergone a right radical mastectomy. Which action should the nurse take to prevent lymphedema development?

Keep both arms below the client’s heart level.

Avoid range-of-motion exercises with the affected arm.

Use the client’s left arm to draw blood samples.

Obtain blood pressure readings using the client’s right arm.

Answer and Explanation

The Correct Answer is C

Choice C.

Choice A rationale

Keeping both arms below the heart level can actually increase the risk of lymphedema development. This position can lead to pooling of lymphatic fluid in the arm, which can exacerbate swelling.

Choice B rationale

Avoiding range-of-motion exercises with the affected arm is not recommended. Regular gentle exercises can help promote lymphatic drainage and prevent lymphedema.

Choice C rationale

Using the client’s left arm (the non-operated arm) to draw blood samples is a recommended practice. This reduces the risk of infection and injury to the right arm, which could potentially trigger or worsen lymphedema.

Choice D rationale

Obtaining blood pressure readings using the client’s right arm (the operated arm) is not recommended. The pressure exerted by the blood pressure cuff can obstruct lymphatic flow and contribute to lymphedema.

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Correct Answer is A

Explanation

A sigmoidoscopy is a procedure used to examine the lower part of the colon (sigmoid colon and rectum). The knee-chest position allows for better visualization of the sigmoid colon by straightening the rectosigmoid junction.

Choice B rationale

The prone position is not typically used for sigmoidoscopy. This position does not provide optimal visualization of the sigmoid colon.

Choice C rationale

The orthopneic position, which involves sitting up and leaning forward, is not used for sigmoidoscopy.

Choice D rationale

The Trendelenburg position, which involves lying flat with the feet elevated higher than the head, is not used for sigmoidoscopy.

A. Mark the edges of steps. B. Use low-wattage light bulbs. C. Place throw rugs over electrical cords. D. Leave doors slightly ajar.

Correct Answer is A

Explanation

Choice A rationale

Marking the edges of steps can help a visually impaired person navigate their home more safely. This can be done with contrasting colors or textures to make the steps more visible.

Choice B rationale

Using low-wattage light bulbs is not recommended for visually impaired individuals. Instead, they may benefit from brighter lighting to enhance visibility.

Choice C rationale

Placing throw rugs over electrical cords is not safe as it can create a tripping hazard. It’s better to secure cords out of walkways.

Choice D rationale

Leaving doors slightly ajar can be dangerous for visually impaired individuals as they may walk into them. It’s safer to keep doors fully open or fully closed.

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A nurse is providing postoperative care for a client who has undergone a right radical mastectomy. Which action should the nurse take to prevent lymphedema development?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a patient for a sigmoidoscopy. In which of the following positions should the nurse place the patient?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about home safety measures with a client who is visually impaired. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

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