Practice Quiz

NCLEX-RN

Category - Physiological

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Which of the following nursing interventions is most appropriate for a female client who underwent radical mastectomy of the right breast?
  1. Turning the client to the back and right side
  2. Measuring the client’s blood pressure on the left arm
  3. Placing the client in semi-Fowler’s position with the affected arm positioned below the level of heart
  4. Assisting the client into a right lateral position, placing a folded towel under the surgical site
Explanation
Answer: B - The client’s right arm should be protected for life. Administration of IVs, injections, and venipunctures, and taking the blood pressure on the involved side must be avoided to prevent lymphedema. The client should be placed in semi-Fowler’s position, with the affected arm elevated and placed above the level of the heart.
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