Difficulty: Medium
Average Score: 90%
Simulated
The nurse caring for a client after right radical mastectomy includes which intervention in the nursing plan of care for this client?
Correct answer
D
Rationale
If there is drainage or bleeding from the surgical site after mastectomy, gravity will cause the drainage to seep down and soak the posterior axillary portion of the dressing first. The nurse checks this area to detect early bleeding. Blood pressure measurement, venipuncture, and intravenous sites should not involve use of the operative arm. The client should be positioned with the head in semi-Fowler's position and the arm on the operative side elevated on pillows to decrease edema.