The nurse is caring for a client who had a left mastectomy several years ago and was admitted to the acute care facility secondary to lymphangitis
What nursing interventions will be included in the plan of care? Standard Text: Select all that apply. 1. Increase activity levels.
2. Elevate left arm.
3. Application of heat to the left arm
4. Massage of the left arm
5. Keep the client in the supine position as often as possible.
2,3
Rationale: Elevating the arm will help to make gravity work with the body to reduce edema, and applications of heat will cause vasodilation, which will also help to remove excess fluid. The nurse must use caution when applying heat to avoid burning the client. Massage of the arm could cause additional trauma. Increasing activity levels will have no helpful affect, and it is not necessary to keep the client supine so long as the arm is elevated in whatever position the client assumes.
You might also like to view...
Which of the following is a true statement about "moderate sedation"?
A) The patient remains conscious but relaxed. B) The patient has the ability to maintain a patent airway independently. C) The patient can respond to verbal directives. D) All of the above.
The nurse is caring for a patient who is to receive a transfusion of packed red blood cells. The patient has a 22-gauge IV in his arm with 0.9% normal saline infusing
What intervention will the nurse perform before obtaining the packed red blood cells from the blood bank? a. Identify the blood group, type, and expiration date with another nurse. b. Insert an 18- or 20-gauge angiocatheter into the patient's other arm. c. Program the IV infusion pump so that the transfusion will complete within 4 hours. d. Obtain a new microdrip tubing and extension tubing from the clean utility room.
A 56 -year-old man is admitted to the emergency room with an acute attack of diverticulitis. The patient has a temperature of 102 ° F, and has an elevated white count. Which assessment would alert the nurse to impending septic shock?
a. Chest pain b. Seizure c. Tachycardia d. Massive diarrhea
The nurse is completing a health history with a client who has complications from chronic asthma. Which open-ended question should the nurse use?
1. "How would you describe your sleep pattern?" 2. "Can you describe your coughing pattern?" 3. "Is there anything that makes your breathing worse?" 4. "What medications are you on?"