乳房切除術後病人，護理師應教導何項措施以預防淋巴水腫？
A client is recovering from a mastectomy. Which instructions should the nurse prioritize to prevent lymphedema?
- AAvoid blood pressure readings on the affected arm✓ 正解避免在患側手臂測量血壓
- BWear tight clothing on the upper arm在上臂穿著緊身衣物
- CKeep the affected arm in a dependent position將患側手臂保持在下垂位置
- DCarry heavy bags with the affected arm用患側手臂提重物
乳房切除術後，患側腋下淋巴結常被清除，導致該側肢體淋巴回流受阻，極易併發淋巴水腫（Lymphedema）。預防的核心在於避免該側肢體受到任何形式的血管損傷、壓力或感染。採取措施包括嚴禁在患側進行侵入性操作（抽血、注射、量血壓），以防止皮膚破損或發炎反應加重水腫。此外，需教導病人避免穿著過緊衣物或提重物，以維持淋巴回流的順暢。
Following a mastectomy, the axillary lymph nodes on the affected side are often removed, impairing lymphatic drainage of that limb and predisposing to lymphedema. The cornerstone of prevention is avoiding any form of vascular trauma, pressure, or infection on the affected arm. Measures include strictly prohibiting invasive procedures (venipuncture, injections, blood pressure measurement) on the affected side to prevent skin breakdown or inflammatory reactions that worsen edema. The client should also be taught to avoid tight clothing and heavy lifting in order to maintain unobstructed lymphatic flow.
在美國臨床護理中，對於患側肢體的保護範疇（Limb Alert）非常嚴格，護理師需在床頭懸掛醒目的警示標語，並嚴格執行相關禁忌，這在美國醫療訴訟防禦中極為重要。