The nurse is working on the general surgical unit and is caring for a patient who has a right total mastectomy. To take the patient's vital signs and to accurately assess the patient's blood pressure, it will be necessary to:
a. place the blood pressure cuff on the left upper arm.
b. place the blood pressure cuff on the right upper arm.
c. place the blood pressure cuff on the right lower arm.
d. use direct (invasive) blood pressure measurement.
A
Determine the best site for blood pressure assessment. Avoid applying the cuff to an extremity when intravenous fluids are infusing, an arteriovenous shunt or fistula is present, or breast or axillary surgery has been performed on that side. The risks associated with invasive blood pressure monitoring require use in an intensive care setting.
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