Best NCLEX-PN Practice Questions Practice Question
The nurse is planning care for the client who had a TRAM (transrectus abdominis myocutaneous) flap breast reconstruction. Which actions should the nurse include?
Correct Answer: B
Rationale: A. Upper-extremity exercise and ROM are restricted to reduce strain on the incision site. B. To monitor for viability and adequacy of blood supply to the TRAM flap, the flap must be assessed hourly for the first 24 hours. C. Pressure over the flap is avoided until healing is complete. D. The affected arm should be elevated to promote venous return.
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