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 D
Explanation
A. This option is primarily aimed at promoting lung expansion and preventing atelectasis (collapse of the lung). While it's an important post-operative intervention, it does not directly reduce the risk of embolic events related to venous thromboembolism.
B. Reporting significant pain (8/10) may indicate complications such as infection or improper healing, but it does not directly relate to reducing the risk of embolic events. While managing pain is important for recovery, simply reporting it does not contribute to preventing VTEs.
C. Assessing popliteal pulses is part of a thorough circulatory assessment, but it mainly focuses on blood flow to the lower extremities rather than preventing embolic events. It can help identify existing DVT but does not actively reduce the risk of embolism.
D. This statement is true and is the best choice for decreasing the risk of an embolic event. Early ambulation promotes venous return, improves circulation, and significantly lowers the risk of DVT and pulmonary embolism in post-operative patients. Encouraging patients to get out of bed and move around as soon as they are stable is a key nursing intervention in post-operative care.
Correct Answer is C
Explanation
A. While having multiple sexual partners is associated with an increased risk of sexually transmitted infections (STIs), it is not considered a significant risk factor for uterine cancer specifically. STIs can contribute to other reproductive cancers, such as cervical cancer, but they are not directly linked to the development of uterine cancer.
B. Smoking is a risk factor for various cancers, including cervical and lung cancers, but its association with uterine cancer is not as strong. While some studies suggest a potential link, it is not recognized as a primary risk factor for uterine cancer.
C. Prolonged exposure to unopposed estrogen (estrogen not balanced by progesterone) is the primary risk factor for uterine cancer. This can occur in situations such as obesity (where adipose tissue produces estrogen), hormone replacement therapy without progesterone, and certain medical conditions like polycystic ovary syndrome (PCOS).
D. Having multiple pregnancies is generally considered to have a protective effect against uterine cancer. Pregnancy reduces the number of menstrual cycles a woman has over her lifetime, which can lead to lower lifetime exposure to estrogen.
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