PN Adult Medical Surgical 2020 - Exam 2
PN Adult Medical Surgical 2020 - Exam 2 ( 91 Questions)
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?
Keeping both arms below the level of the client's heart can increase venous pressure and fluid accumulation in the affected arm, which can lead to lymphedema.
Using the client's left arm to obtain blood samples is a correct action to prevent lymphedema. The nurse should avoid any invasive procedures, such as blood draws, injections, or IV insertions, on the affected arm to reduce the risk of infection and injury.
Obtaining blood pressure readings using the client's right arm is an incorrect action that can increase lymphatic fluid accumulation and impair circulation in the affected arm.
Limiting range-of-motion exercises with the affected arm is an incorrect action that can decrease lymphatic drainage and increase swelling in the affected arm. The nurse should encourage the client to perform gentle exercises, such as squeezing a soft ball or raising and lowering the arm, to promote lymphatic flow and prevent stiffness.
Choice A reason: Keeping both arms below the level of the client's heart can increase venous pressure and fluid accumulation in the affected arm, which can lead to lymphedema.
Choice B reason: Using the client's left arm to obtain blood samples is a correct action to prevent lymphedema. The nurse should avoid any invasive procedures, such as blood draws, injections, or IV insertions, on the affected arm to reduce the risk of infection and injury.
Choice C reason: Obtaining blood pressure readings using the client's right arm is an incorrect action that can increase lymphatic fluid accumulation and impair circulation in the affected arm.
Choice D reason: Limiting range-of-motion exercises with the affected arm is an incorrect action that can decrease lymphatic drainage and increase swelling in the affected arm. The nurse should encourage the client to perform gentle exercises, such as squeezing a soft ball or raising and lowering the arm, to promote lymphatic flow and prevent stiffness.