A student nurse is preparing to take a blood pressure (BP) on a client who has a peripheral IV line in the left arm. What instruction by the faculty member is most important?
a. "Use the arm that doesn't have the IV site in it."
b. "Don't inflate the cuff too high if you use the left arm."
c. "Make sure the IV line is secure before taking the BP."
d. "While the BP is taken, a little backflow of the IV is okay."
A
Nurses should not take blood pressure on arms that have IVs because increased pressure can cause infiltration and can cause fluid to leak from the insertion site. Because the affected arm should not be used for BP, none of the other options can be correct.
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