A nurse is caring for a client 1 day after a left-sided mastectomy with lymph node dissection. Which nursing intervention is the priority in caring for this client?

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After a mastectomy, an important goal is restoring function in the client's affected arm. Measures to promote function are initiated immediately after surgery. Elevating the affected arm to heart level (eg, on a pillow) is crucial to reduce fluid retention and prevent lymphedema in the affected arm (Option B). Hand and arm exercises are implemented gradually, beginning with finger flexion and extension. These activities maintain muscle tone, prevent contractures, and improve lymph and blood circulation, which promote function and also prevent lymphedema. The return of full range of motion in the affected arm is desired within 4-6 weeks. Additional nursing care for clients after a mastectomy includes keeping the client in semi-Fowler position and placing a sign over the bed that specifies, "No blood pressure, venipuncture, or injections on left arm," as these actions could cause lymphedema. (Option A) Ice reduces inflammation, swelling, and pain. Although this reduces discomfort, it does not directly contribute to restoring arm function and is not the priority. (Option C) Frequent ambulation is not the priority in the initial postoperative period as it does not facilitate lymph drainage or help restore arm function. (Option D) Pneumatic compression devices may be used to facilitate lymph drainage when lymphedema is present. Elevating and exercising the arm help prevent lymphedema from developing and are priority in this client. Educational objective: A priority goal for a client following a mastectomy is restoring function in the affected arm. Elevation of the arm and institution of arm exercises begin immediately following surgery to prevent lymphedema.

A Nurse Is Caring for a Client 1 Day After