NORCET 6 Prelims -2024: A patient in post-op area after having right side mastectomy. What should be the priority care in this patien…

NORCET 6 Prelims -2024

Medical & Surgical Nursing

Medium

Appeared in: NORCET 6 Prelims -2024

Explanation

The correct action is to take the blood pressure from the left side, which is the non-operative arm.
This is a critical safety measure to prevent lymphedema, a chronic swelling that can occur after lymph node removal.
The pressure from a blood pressure cuff on the surgical side can damage the remaining lymphatic vessels and obstruct drainage.
Prioritizing the correct site for blood pressure measurement directly prevents a significant, long-term complication.

Option A: This action is contraindicated. Applying a BP cuff to the arm on the same side as a mastectomy can cause lymphedema.
Option C: While monitoring oxygen saturation is a standard part of post-operative care, and the left side is the correct location, it is not the highest priority action in this specific context. The immediate risk of harm from improper BP measurement is greater.
Option D: This action should be avoided. The principle is to avoid any constrictive items on the affected limb. While a pulse oximeter is less constrictive than a BP cuff, the unaffected arm is the preferred site.

Clinical Relevance

Nursing practice connection: Safe nursing care depends on performing Post-operative care following a mastectomy and prevention of lymphedema in the correct sequence, documenting the action clearly, and monitoring for the expected response.
A core nursing responsibility is to protect the limb on the side of a mastectomy. This includes clear communication during handoffs and ensuring 'Limb Alert' signs are visible.
Patient education is crucial. The patient and their family must understand the lifelong precautions needed for the affected arm.
What if? If the patient had a bilateral mastectomy, blood pressure should be taken on the thigh using an appropriately sized cuff. The forearm could be an alternative in some cases, but the thigh is preferred.

How to Approach the Question

First, identify the patient's condition: post-operative right mastectomy.
Recall the major complications associated with this surgery. The removal of axillary lymph nodes creates a lifelong risk of lymphedema.
Analyze the options based on the principle of preventing lymphedema, which involves avoiding any constriction (like a BP cuff) on the affected arm.
Evaluate the priority. The action that prevents the most significant and specific harm is the highest priority. In this case, avoiding the BP cuff on the right arm is a critical safety measure.
Select the option that reflects this critical safety precaution: taking the BP on the opposite, unaffected arm.

Concept Tested & Keywords

Concept Tested: Post-operative care following a mastectomy and prevention of lymphedema.
Stem keywords: post-op, right side mastectomy, priority care
Lead-in keywords: What should be the priority care
Clinical cues: The patient's specific surgery (right side mastectomy) is the most important cue, as it dictates specific contraindications for care.

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