Postoperative care for a client who has had a right-sided mastectomy with a drain: which action should the nurse take?

• A. Dangle the operative limb for 5 minutes every hour.
• B. Head of the client's bed at a 15° angle.
• C. Take blood pressures on the client's non-affected arm.
• D. Keep the wound drain evacuator fully expanded at all times.

Answer: (C)

After mastectomy with a drain, protecting the affected arm from pressure and trauma is essential because the surgery disrupts lymphatic drainage. This puts the arm at risk for lymphedema and infection if the arm is used for blood pressure, IVs, or frequent venipunctures. Therefore, taking blood pressures on the non-affected arm is the safer, best choice to prevent edema and complications in the operated side.

Dangle the operative limb frequently is not advised because sudden dependent positioning can increase swelling and may stress the incision or drain. A modest elevation of the arm is usually used to reduce edema, not letting it hang.

Elevating the head of the bed only 15 degrees doesn’t optimally support drainage or lung expansion; a higher, appropriate incline is typically used to aid breathing and reduce edema.

Keeping the wound drain evacuator fully expanded at all times would eliminate suction, since these drains rely on a compressible bulb to create negative pressure. The evacuator should be maintained to provide proper suction, not kept in a fully expanded state.