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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Choosing fortified foods containing vitamin B2 is a good practice. Vitamin B2, also known as riboflavin, is important for energy production and cellular function, and older adults may need more of this nutrient.
Choice B rationale
Decreasing fluid intake is not generally recommended for older adults. Adequate hydration is important for many body functions, including maintaining blood volume and preventing constipation.
Choice C rationale
Limiting intake of plant-based foods is not a healthy practice. Plant-based foods are rich in fiber, vitamins, and minerals, and they can help reduce the risk of chronic diseases.
Choice D rationale
Decreasing daily intake of protein is not generally recommended for older adults. Protein is essential for maintaining muscle mass, which tends to decrease with age.
Correct Answer is D
Explanation
Choice A rationale
Elevating the head of the bed 45 degrees before starting the CPM device is not necessary. The position of the bed does not affect the operation of the CPM device.
Choice B rationale
Instructing the patient to increase the degree of flexion as tolerated is not the nurse’s responsibility. The degree of flexion is usually set by the healthcare provider or physical therapist.
Choice C rationale
Ensuring the frame joint is in a flexed position before placing the leg onto the device is not necessary. The CPM device should be set up according to the manufacturer’s instructions and the healthcare provider’s orders.
Choice D rationale
Ensuring the knee joint is positioned over the CPM device frame joint is crucial. Proper alignment of the patient’s knee joint with the CPM device’s joint ensures effective and safe operation of the device.
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