Safe, Effective Care Environment
44. Which nursing action is appropriate in the care of a client admitted with pneumonia who had a right mastectomy 3 years ago?
Safe, Effective Care Environment
44. Which nursing action is appropriate in the care of a client admitted with pneumonia who had a right mastectomy 3 years ago?
. Check right radial pulse every 4 hours.
. Start an IV on the left forearm.
. Keep the right arm below heart level.
. Avoid range of motion on right arm.
Test-Taking Tip
Three of the choices relate to the right arm, only one the left arm. Choose the option, in this case, that is different.
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/Potential for Alterations in Body Systems
Safe, Effective Care Environment
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Answer 1 is incorrect because neither the mastectomy nor the pneumonia puts the client at risk for problems with arterial circulation. It is not necessary to do frequent pulse checks. Answer 2 is correct because, during breast surgery, lymph nodes are removed to rid the body of spreading cancer. This leaves the distal tissue at risk for swelling and infections. IV catheters, carrying a risk of infection, should be placed in the opposite arm. Answer 3 is incorrect because lymph nodes may have been removed from the right auxiliary area with the mastectomy; the client is at risk for arm swelling. Raising the arm is permitted and may help minimize swelling. Answer 4 is incorrect because movement of the right arm will help promote venous return in this arm with limited lymphatic damage.