A client has just returned from a right radical mastectomy. Which action by the assistive personnel (AP) would require the nurse to intervene?

Choice A rationale Checking the amount of urine output in the catheter collection bag is a routine and appropriate task for assistive personnel (AP). This action helps the nurse monitor the client's renal perfusion and fluid balance post-surgery. A normal output is typically at least 30 mL/hr, and this observation does not interfere with the surgical site or pose a risk to the client's recovery following a right radical mastectomy. Choice B rationale Elevating the right arm on a pillow is a recommended intervention after a right radical mastectomy. This positioning promotes lymphatic and venous drainage from the surgical side, which helps prevent lymphedema. This common postoperative complication is caused by the removal of lymph nodes, and proper elevation is a key nursing intervention to mitigate swelling. Choice C rationale Taking the blood pressure on the right arm after a right radical mastectomy is a contraindicated and harmful action. Lymph node removal impairs lymphatic drainage, and applying pressure from a blood pressure cuff can further obstruct circulation, significantly increasing the client's risk for developing or exacerbating lymphedema on the affected side. Blood pressure must be taken on the unaffected left arm. Choice D rationale Encouraging the client to squeeze a rolled washcloth is an appropriate and beneficial activity. This exercise gently promotes muscle contraction and early range of motion in the affected arm, which helps prevent joint stiffness and blood clot formation. It aids in gradual physical rehabilitation without placing excessive strain on the surgical incision site.