The nurse is assisting the wife of a client who has been ...

[tfester]

The nurse is assisting the wife of a client who has been diagnosed with hypertension to monitor his blood pressure. The nurse states that the blood pressure should be taken: (Select all that ap-ply.)
 
  1. At the same time each day
  2. On the same arm each time
  3. In the same position each time
  4. After the client has had a brief rest
  5. After his blood pressure medication
  6. Right before getting up in the morning

Question 2

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.

[AngeliqueG]

Answer to Question 1

ANS: 1, 2, 3, 4
Instruct the client or primary caregiver to take BP at same time each day and after the client has had a brief rest. Take BP sitting or lying down; use the same position and arm each time pressure is taken. The other options are not necessary because they do not affect blood pressure readings.

Answer to Question 2

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.

[tfester]

Excellent

[isabelt_18]

Gracias!