Which is an appropriate nursing intervention when using an alternate site for taking blood pressure (BP)?
A) Do not use the same site continuously throughout the client's care.
B) Document the site where BP values were measured.
C) Place the client in semi-Fowler's position.
D) Measure the respiratory rate along with the BP.
B
Feedback:
If using an alternate site for taking BP, the nurse should identify it in the documentation and use the same site continuously throughout the client's care to maintain comparable data. The nurse should be sure to document where BP values were measured if the site is unusual. It is not necessary to place the client in a semi-Fowler's position; the nurse should assist the client to a comfortable position before taking the BP. It is also not necessary to measure the respiratory rate along with the BP.
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