QuestionMay 28, 2025

Which nursing intervention would the nurse perform for a patient who is 24 hours postoperative after a modified radical mastectomy of the left breast? Monitor the patient for signs of shock or hemorrhage. Keep the patient flat in bed and turn the patient every 2 to 4 hours. When measuring vital signs take the blood pressure using the patient's left arm. Teach the patient not to lift heavy items with the affected arm for 6 to 8 days.

Which nursing intervention would the nurse perform for a patient who is 24 hours postoperative after a modified radical mastectomy of the left breast? Monitor the patient for signs of shock or hemorrhage. Keep the patient flat in bed and turn the patient every 2 to 4 hours. When measuring vital signs take the blood pressure using the patient's left arm. Teach the patient not to lift heavy items with the affected arm for 6 to 8 days.
Which nursing intervention would the nurse perform for a patient who is 24 hours
postoperative after a modified radical mastectomy of the left breast?
Monitor the patient for signs of shock or hemorrhage.
Keep the patient flat in bed and turn the patient every 2 to 4 hours.
When measuring vital signs take the blood pressure using the patient's left arm.
Teach the patient not to lift heavy items with the affected arm for 6 to 8 days.

Solution
4.3(231 votes)

Answer

Monitor the patient for signs of shock or hemorrhage. Explanation 1. Identify Appropriate Postoperative Care After a modified radical mastectomy, it is crucial to monitor for complications such as shock or hemorrhage. This involves checking vital signs and observing for any signs of excessive bleeding or instability. 2. Evaluate Positioning and Movement Keeping the patient flat in bed is not typically recommended; instead, elevating the head of the bed can help with breathing and comfort. Turning every 2 to 4 hours is standard to prevent pressure ulcers. 3. Assess Blood Pressure Measurement Protocol Blood pressure should not be taken on the affected arm (left arm in this case) to avoid lymphedema risk. 4. Educate on Activity Restrictions Patients are generally advised not to lift heavy items with the affected arm, but the restriction period is usually longer than 6 to 8 days, often extending to several weeks.

Explanation

1. Identify Appropriate Postoperative Care<br /> After a modified radical mastectomy, it is crucial to monitor for complications such as shock or hemorrhage. This involves checking vital signs and observing for any signs of excessive bleeding or instability.<br /><br />2. Evaluate Positioning and Movement<br /> Keeping the patient flat in bed is not typically recommended; instead, elevating the head of the bed can help with breathing and comfort. Turning every 2 to 4 hours is standard to prevent pressure ulcers.<br /><br />3. Assess Blood Pressure Measurement Protocol<br /> Blood pressure should not be taken on the affected arm (left arm in this case) to avoid lymphedema risk.<br /><br />4. Educate on Activity Restrictions<br /> Patients are generally advised not to lift heavy items with the affected arm, but the restriction period is usually longer than 6 to 8 days, often extending to several weeks.
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