The nurse is assessing a patient after a mastectomy and thinks the patient's affected arm appears swollen. What is the best way to verify this finding?
a. Measure and document the circumference of the arm.
b. Measure and compare the circumferences of both arms.
c. Press a finger into the arm and measure the indentation.
d. Ask the patient to hang the arm down for 3 minutes and check for increased swelling.
ANS: B
The best way to verify if the affected arm is swollen is to measure and comparing the affected side with the patient's opposite side. A. C. Measuring, checking for pitting edema and documenting are not as significant if not compared with the normal side. D. Hanging the arm down will not help and may worsen the swelling.
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