The nurse is caring for a client diagnosed with breast cancer who underwent a left-sided mastectomy two days prior

Question

The nurse has delegated vital signs on this client to the unlicensed assistive personnel (UAP). What specific instructions should the nurse provide to the (UAP) in delegating this task?
1. Take the blood pressure on the right arm.
2. No special instructions are needed.
3. Take the blood pressure on the left arm.
4. Take the blood pressure on both arms for a baseline.

Answer 1

Correct Answer: 1

The blood pressure should be taken in the arm opposite the surgical site. Blood pressures should not be taken on the same side as a mastectomy. It should also not be taken on an arm with a shunt, trauma, or disease. If this is not possible, then a thigh pressure should be obtained. The nurse should be sure to provide the PCA with instructions to use the arm opposite the surgical site for blood pressure readings. The left arm should not be used for blood pressure readings, intravenous fluids, or other invasive procedures. It is not possible to take the blood pressure using both arms, since the left arm should never be used again for blood pressure readings. If bilateral readings become necessary, the thighs should be used so that a comparison can be made.