The nurse has asked the assistive personnel to take the blood pressure

The nurse has asked the assistive personnel to take the blood pressure of a client who experienced a left mastectomy 3 days ago.

Which of the following statements by the assistive personnel shows the best understanding re-garding the appropriate assessment technique for this particular client?
1. “Is there anything affecting her right arm?”
2. “Has she been experiencing any edema in that left arm?”
3. “How long has it been since she had her breast removed?”
4. “I’ll wait until she’s been medicated for pain before I take it.”

ANSWER

ANS: 1
Avoid applying the cuff to the extremity when intravenous fluids are infusing; an arteriovenous shunt or fistula is present; breast or axillary surgery has been performed on that side; or the ex-tremity has been traumatized, diseased, or requires a cast or bulky bandage. The answer reflects an understanding that the right arm is the extremity of choice for monitoring this client’s blood pressure.