Which nursing action should be included in the plan of care for a patient returning to the surgical unit following a left modified radical mastectomy with dissection of axillary lymph nodes?
a. Obtain a permanent breast prosthesis before the patient is discharged from the hospital.
b. Teach the patient to use the ordered patient-controlled analgesia (PCA) every 10 minutes.
c. Post a sign at the bedside warning against venipunctures or blood pressures in the left arm.
d. Insist that the patient examine the surgical incision when the initial dressings are removed.
ANS: C
The patient is at risk for lymphedema and infection if blood pressures or venipuncture are done on the right arm. The patient is taught to use the PCA as needed for pain control rather than at a set time. The nurse allows the patient to examine the incision and participate in care when the patient feels ready. Permanent breast prostheses are usually obtained about 6 weeks after surgery.
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