The nurse is caring for a client that has undergone a modified left radical mastectomy with lymph node removal. Which intervention would assist in preventing lymphedema?
Avoiding arm exercise in the immediate post-op period
Instruct the client to sleep in the left lateral side lying position
Placing cool compresses on the affected arm
Elevating the affected arm on a pillow above the level of the heart
The Correct Answer is D
A. This statement is not advisable. While it is essential to avoid strenuous activity initially, gentle arm exercises and range-of-motion activities are generally encouraged as soon as possible to promote circulation and help prevent lymphedema. Immobilization can actually increase the risk of lymphedema.
B. This intervention is not recommended for preventing lymphedema. Sleeping on the side of the surgery (in this case, the left side) can put pressure on the affected arm and may not promote proper lymphatic drainage. Clients are often advised to sleep on their back or to position themselves in a way that does not compress the affected arm.
C. This intervention can provide temporary relief if there is swelling or discomfort, but it does not effectively prevent lymphedema. While cool compresses might help reduce inflammation, they are not a primary measure for lymphedema prevention.
D. This is the most effective intervention for preventing lymphedema. Elevating the affected arm helps facilitate lymphatic drainage and reduces the risk of fluid accumulation. Keeping the arm elevated above heart level encourages proper circulation and helps manage swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. After a radical cystectomy, the client may have a urinary diversion (such as a stoma) and should be vigilant about monitoring urine output. Absence of urine output can indicate a serious issue, and notifying the provider is crucial.
B. This statement indicates a need for further clarification. After a radical cystectomy, clients typically do not resume normal voiding because the bladder is removed. Instead, they may have a urinary diversion or need to learn how to manage their new urinary output. Normal voiding as before surgery is not possible, so this statement reflects a misunderstanding of the procedure's implications.
C. After surgery, particularly abdominal surgery like a radical cystectomy, patients are often advised to take stool softeners to prevent constipation. Straining can increase the risk of complications and affect the surgical site, so this is a valid precaution.
D. Monitoring the surgical site for signs of infection, such as redness, swelling, or discharge, is an essential part of post-operative care. Clients should be educated on how to check their surgical site for any concerning changes.
Correct Answer is A
Explanation
A. The elevated pH and decreased PaCO2 indicate that the respiratory system is causing alkalosis, typically due to hyperventilation (excessive breathing).
B. Metabolic alkalosis would be indicated by a high pH with a normal or high HCO3. Since the HCO3 level is normal and the PaCO2 is low, this does not fit the picture of metabolic alkalosis.
C. Respiratory acidosis would be characterized by a low pH and an elevated PaCO2 due to inadequate ventilation and accumulation of carbon dioxide. Here, the pH is high, and the PaCO2 is low.
D. Metabolic acidosis would be indicated by a low pH with a low HCO3. In this case, the pH is high, and the HCO3 is normal.
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