In developing a nursing plan of care for a client who has a venous access device, which of these notations is essential to include?
a. "Do not measure blood pressure on the involved side."
b. "Maintain accurate measurement of intake and output at all times."
c. "Provide assistance with activities of daily living."
d. "Require a family member to remain with the client overnight to ensure assistance."
A
When obtaining a blood pressure, the nurse should not use the extremity that has a venous access device, has a dialysis fistula or graft, or is on the same side on which the client has had a mastectomy.
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