The nurse is preparing to measure the patient's blood pressure with an electronic blood pressure device. Which concept is most important for the nurse to consider?
a. Use the extremity closest to the nurse.
b. The cuff size must match the extremity being used.
c. The brachial artery is always the best one to use.
d. The temporal artery is used if neither arm is available.
B
The cuff must be the appropriate size for the extremity used. If the thigh is used, the nurse must use a larger cuff. The extremity used has nothing to do with proximity to the nurse. It depends on the patient's status. In some instances the brachial artery in the upper arm is not available for blood pressure assessment such as after a mastectomy, if the extremity is injured, or if an intra-venous line is in place. The temporal artery is impossible to use for blood pressure measurement because the temporal arteries are on the lateral aspects of the skull.
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