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

Rationale: A. This is an appropriate task for the assistive personnel (AP). Monitoring urine output helps assess hydration and kidney function and does not pose any risk to the surgical site or affected limb. B. This is an appropriate action after a mastectomy. Gentle hand-squeezing or ball-squeezing exercises promote circulation, prevent stiffness, and reduce lymphedema in the affected extremity, as long as they are performed according to postoperative instructions. C. This action requires immediate nurse intervention. Following a radical mastectomy, the client is at risk for lymphedema on the affected side due to removal of lymph nodes. Blood pressure measurements, venipunctures, or injections should never be performed on the surgical side, as these can increase lymphatic pressure and worsen swelling or infection. D. Elevation of the arm on the affected side promotes venous and lymphatic drainage, helping to prevent lymphedema and reduce postoperative swelling.