A woman who has undergone a right-sided modified-radical mastectomy returns from surgery. Which nursing intervention would be most appropriate at this time?

Question

A) Ask the client how she feels about having her breast removed.
B) Attach a sign above her bed to have BP, IV lines, and lab work in her right arm.
C) Encourage her to turn, cough, and deep breathe at frequent intervals.
D) Position her right arm below heart level.

Answer 1

C
Response:
Upon return from surgery, the nurse should encourage the client to turn, cough, and deep breathe at frequent intervals, at least every 2 hours, to help expand collapsed alveoli, clear inhalation anesthetic agents from the body, and prevent postoperative atelectasis and pneumonia. Asking the client how she feels about her breast removal should be done at a later time, when she is more alert and oriented and has had time to think about what has happened. The sign should state that no BP, IV lines, and lab work should be done on the client's right arm. The right arm should be elevated on a pillow to promote lymph drainage.