# A nurse is caring for a 38-year-old client who underwent a radical mastectomy 12 hours ago. Which assessment finding should be the nurse's priority concern? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=540635 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a 38-year-old client who underwent a radical mastectomy 12 hours ago. Which assessment finding should be the nurse's priority concern? ## 보기 1. Mild incisional pain rated 4/10 on the pain scale 2. Absence of radial pulse on the affected side with cool, pale fingers **✔ 정답** 3. Serosanguineous drainage in the Jackson-Pratt drain 4. Decreased range of motion in the affected arm **정답: 2** ## 해설 Absence of radial pulse with cool, pale fingers indicates compromised circulation post-mastectomy, a medical emergency requiring immediate intervention to prevent tissue necrosis. Other findings (mild pain, serosanguineous drainage, decreased ROM) are expected or less urgent. ## 심화 해설 Priority Assessment After Radical Mastectomy The correct answer is 2. Absence of radial pulse on the affected side with cool, pale fingers. This finding indicates an acute vascular compromise, which represents a life- or limb-threatening emergency and must be addressed immediately. Analysis of the Priority Finding The absence of a radial pulse coupled with cool, pale skin on the affected side is a classic presentation of acute arterial insufficiency. Following a radical mastectomy, this can occur due to several mechanisms, including direct vascular injury, thrombosis, or external compression from a tight surgical dressing or developing hematoma. The "6 P's" of acute arterial occlusion—pain, pallor, pulselessness, paresthesia, poikilothermia (coolness), and paralysis—guide the assessment. The presence of pulselessness and pallor indicates that oxygenated blood is not reaching the distal extremity. Without prompt intervention, irreversible tissue ischemia and necrosis can develop within hours, potentially leading to loss of limb function. This directly threatens the client's physiological integrity, placing it at the highest priority level according to the airway, breathing, circulation (ABC) framework, where circulation to a vital extremity is a critical component. Why Other Options Are Not the Priority - Option 1 describes mild incisional pain. A pain score of 4/10 is an expected finding 12 hours postoperatively. While effective pain management is a core nursing responsibility and a key component of enhanced recovery after surgery, it does not signal an immediate threat to the client's survival or limb integrity. The provided research by Abd El-Rahman et al. (2025) explores analgesic efficacy, comparing techniques like wound instillation and nerve blocks to manage this very type of postoperative pain, confirming it is an anticipated and manageable aspect of recovery [1]. - Option 3 notes serosanguineous drainage in the Jackson-Pratt drain. This is a normal and expected finding in the immediate postoperative period. The drainage results from the surgical disruption of capillaries and lymphatic vessels. The drain's purpose is to remove this fluid to prevent seroma formation and promote wound healing. The nurse should monitor the amount and character of the drainage, but its presence alone is not a priority concern. - Option 4 identifies a decreased range of motion in the affected arm. This is an anticipated consequence of surgery, pain, and the presence of surgical drains. While early and progressive arm exercises are a critical part of postoperative rehabilitation to prevent long-term complications like lymphedema and frozen shoulder, this finding does not constitute an immediate threat. It is a rehabilitation-focused concern that is addressed after stabilization and confirmation of adequate tissue perfusion. Clinical Reasoning and Test-Taking Strategy This question tests the ability to distinguish between an expected postoperative finding and an emergent complication. The nursing process requires continuous assessment and clinical judgment to prioritize care. Using Maslow's hierarchy of needs and the ABC framework, a circulatory problem (absence of pulse) takes absolute precedence over a comfort issue (pain), a normal physiological response (drainage), or a mobility concern (range of motion). The nurse's immediate action upon finding an absent radial pulse would be to perform a comprehensive neurovascular assessment, immediately notify the surgeon, and prepare for potential interventions such as loosening constrictive dressings or facilitating a return to the operating room for vascular exploration.References (research sources) - [1]Could Wound Instillation Provide an Efficient Analgesia Comparable to That Provided by PECS-II Block for Modified Radical Mastectomy Using Ketamine-Bupivacaine Combination? A Pilot Study.Research articleAbd El-Rahman AM, Khalaf SEG, Bakri MH. (2025) · DOI: 10.2147/lra.s515752 ## 임상 시나리오 Clinical Priority: Acute Limb Ischemia Post-Mastectomy Situation A 38-year-old client is 12 hours post-radical mastectomy. The nurse identifies an absent radial pulse on the affected side, with the fingers appearing cool and pale. This assessment finding constitutes a limb-threatening emergency. Background Acute arterial insufficiency following breast surgery can result from direct vascular trauma, thrombosis, or external compression by a constrictive dressing or expanding hematoma. The 6 P's (Pain, Pallor, Pulselessness, Paresthesia, Poikilothermia, Paralysis) are the hallmark assessment findings. Irreversible tissue damage can begin within 4-6 hours of complete arterial occlusion. Assessment - **Neurovascular Checks:** Perform immediate and serial assessments of the affected extremity, comparing bilaterally. Document pulse quality (Doppler if non-palpable), capillary refill, skin color, temperature, sensation, and motor function. - **Dressing Inspection:** Assess the surgical dressing and any circumferential bandages for excessive tightness. A tight dressing can act as a tourniquet. - **Drain Output:** Evaluate Jackson-Pratt drain output for sudden increases or cessation, which may indicate a developing hematoma causing compression. - **Pain Assessment:** Note any sudden, severe, or disproportionate pain in the extremity, which is an early sign of compartment syndrome or ischemia. Recommendations - **Immediate Action:** If a tight dressing is identified, the nurse should immediately loosen or release it per facility protocol and reassess circulation promptly. - **Escalation:** Notify the surgeon or Rapid Response Team immediately. This is a surgical emergency that may require wound exploration, hematoma evacuation, or vascular surgical intervention. - **Positioning:** Keep the affected extremity at the level of the heart (neither dependent nor elevated) to optimize arterial perfusion pressure without compromising venous return. - **Documentation:** Meticulously document the time of finding, all assessment data, notifications made, and interventions performed. ## 핵심 개념 - **Acute Arterial Insufficiency** — A sudden lack of oxygenated blood flow to an extremity, often presenting with the 6 P's: Pain, Pallor, Pulselessness, Paresthesia, Poikilothermia, and Paralysis. - **Radical Mastectomy** — A surgical procedure involving removal of the entire breast, underlying chest muscle, and axillary lymph nodes, which carries a risk of neurovascular injury. - **ABC Framework** — A prioritization method in nursing (Airway, Breathing, Circulation) used to identify and manage life-threatening conditions first. - **Jackson-Pratt Drain** — A closed-suction medical device used to remove fluids from a surgical site, commonly placed after a mastectomy to prevent seroma formation. - **6 P's of Vascular Compromise** — A classic set of assessment findings for acute limb ischemia: Pain, Pallor, Pulselessness, Paresthesia, Poikilothermia (coolness), and Paralysis. ## 같은 주제 문제 - [A nurse is caring for a 72-year-old client who underwent a splenectomy 48 hours ago. Which…](https://mymerci.kr/pages/nclex_q.php?qn_id=540634) - [A nurse is caring for a client who underwent a radical mastectomy 24 hours ago. Which asse…](https://mymerci.kr/pages/nclex_q.php?qn_id=540636) - [A nurse is caring for a client who underwent a splenectomy 12 hours ago. Which assessment …](https://mymerci.kr/pages/nclex_q.php?qn_id=540637) - [A nurse is caring for a client who underwent a splenectomy 24 hours ago following severe a…](https://mymerci.kr/pages/nclex_q.php?qn_id=540638) - [A nurse is caring for a client who underwent a radical mastectomy 24 hours ago. Which nurs…](https://mymerci.kr/pages/nclex_q.php?qn_id=540639) - [A nurse is caring for a client who underwent a splenectomy 12 hours ago. Which nursing int…](https://mymerci.kr/pages/nclex_q.php?qn_id=540640) - [A nurse is caring for a patient who underwent a bone marrow biopsy 2 hours ago. Which nurs…](https://mymerci.kr/pages/nclex_q.php?qn_id=540641) - [A patient is scheduled for a splenectomy due to idiopathic thrombocytopenic purpura (ITP).…](https://mymerci.kr/pages/nclex_q.php?qn_id=540642) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._