A patient returns to the surgical unit following a right modified radical mastectomy with dissection of axillary lymph nodes.Postoperative orders include diet as tolerated,up to ad libitum,Hemovac drain,and patient-controlled analgesia (PCA)at 1 mg morphine every 10 minutes.What is an appropriate intervention for the nurse to include in implementing postoperative care for the patient?

Question

Quizplus · Accepted Answer

Posting a sign at the bedside warning against blood pressures or venipunctures on the right arm is an appropriate intervention as it helps prevent lymphedema. Since lymph nodes have been removed, there is a risk of lymphatic system becoming compromised leading to swelling in the arm if blood pressure cuffs or venipuncture is performed on the affected side. Options A, B, and D are not appropriate interventions. Teaching the patient to use the PCA every 10 minutes may result in overmedication and harm the patient. Insisting that the patient examine the incision can increase risk of infection. Encouraging the patient to obtain a permanent breast prosthesis is not appropriate for immediate postoperative care.

A Patient Returns to the Surgical Unit Following a Right