The nurse is caring for a woman who had a right-sided mastectomy 2 years ago. What action by the nurse is most appropriate?
a. Place a sign above the bed: "No blood pressures on the right arm."
b. Place a sign above the bed: "No continuous blood pressures on the right arm."
c. Place a sign above the bed: "Blood pressures in legs only."
d. No specific action is needed for this situation.
ANS: A
After a mastectomy or after lymph nodes have been removed, the patient should not have blood pressures taken on the operative side. Doing so can cause lymphedema. The nurse communicates this to all staff with a sign stating that no blood pressures are to be taken on the right side. The other actions are not warranted.
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