A client has just returned from a right radical mastectomy. Which action by the unlicensed assistive personnel (UAP) would the nurse consider unsafe?
a. Checking the amount of urine in the urine catheter collection bag
b. Elevating the right arm on a pillow
c. Taking the blood pressure on the right arm
d. Encouraging the client to squeeze a rolled washcloth
ANS: C
Health care professionals need to avoid the arm on the side of the surgery for blood pressure measurement, injections, or blood draws. Since lymph nodes are removed, lymph drainage would be compromised. The pressure from the blood pressure cuff could promote swelling. Infection could occur with injections and blood draws. Checking urine output, elevation of the affected arm on a pillow, and encouraging beginning exercises are all safe postoperative interventions.
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