A nurse is assisting with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation. Which of the following actions should the nurse take? (Select all that apply.)
Inspect the electrode pads
Instruct the client not to talk during the test
Administer an analgesic prior to the procedure
Wash the skin with plain water before placing the electrodes
Keep the client NPO after midnight
Correct Answer : A,B
Choice A: Inspecting the electrode pads is an action that the nurse should take. The electrode pads are adhesive patches that atach to the skin and connect to the ECG machine. The nurse should inspect the electrode pads for expiration date, cleanliness, and stickiness, and replace them if necessary. The nurse should also check for any signs of skin irritation or allergy from the electrode pads.
Choice B: Instructing the client not to talk during the test is an action that the nurse should take. Talking during the test can interfere with the ECG recording and cause artifacts or false readings. The nurse should instruct the client to remain still and quiet during the test, and avoid any movements or activities that can affect the heart rate or rhythm, such as coughing, deep breathing, or shivering.
Choice C: Administering an analgesic prior to the procedure is not an action that the nurse should take. An analgesic is a pain reliever that can be given orally, intravenously, or topically. An analgesic is not necessary for an ECG, as it is a noninvasive and painless procedure. An analgesic can also alter the heart rate or rhythm and affect the ECG results. The nurse should only administer an analgesic if prescribed by the provider for another reason.
Choice D: It is more common to use alcohol swabs, and not water, to clean the skin as they are better at removing oils and ensuring good adhesion of the electrodes.
Choice E: Keeping the client NPO after midnight is not an action that the nurse should take. NPO means nothing by mouth, which is a restriction of food and fluids before certain procedures or surgeries. NPO is not required for an ECG, as it does not involve any anesthesia or sedation. The nurse should allow the client to eat and drink normally before and after the test, unless instructed otherwise by the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: B. Initiate oxygen therapy.
Choice A reason:
Attaching the leads for a 12-lead ECG is crucial for diagnosing a myocardial infarction. However, it is not the first priority. Ensuring the patient receives adequate oxygen is more critical to prevent further myocardial damage. The ECG can be performed immediately after oxygen therapy is initiated to confirm the diagnosis and guide further treatment.
Choice B reason:
Initiating oxygen therapy is the first priority because it ensures that the heart muscle receives adequate oxygen, which is essential to prevent further damage during a myocardial infarction. Oxygen therapy helps to maintain tissue oxygenation and can reduce the extent of myocardial injury. This immediate intervention is vital to stabilize the patient and improve outcomes.
Choice C reason:
Inserting the IV catheter is important for administering medications and fluids. However, it is not the first step. Oxygen therapy takes precedence to ensure the heart and other vital organs receive sufficient oxygen. Once oxygen is administered, IV access can be established to facilitate further treatment.
Choice D reason:
Obtaining a blood sample is necessary for confirming the diagnosis and assessing cardiac markers. However, it is not the immediate priority. Ensuring the patient is oxygenated is more urgent to prevent further myocardial damage. Blood samples can be drawn after oxygen therapy is initiated.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because this client has signs of brain death, such as severe head injuries, low respiratory rate, and unresponsiveness. The nurse should tag this client as black, which means deceased or expectant.
Choice B Reason: This is incorrect because this client has non-life-threatening injuries, such as a simple fracture and scratches. The nurse should tag this client as green, which means minor or delayed care.
Choice C Reason: This is incorrect because this client has minor injuries and is able to walk around. The nurse should tag this client as green, which means minor or delayed care.
Choice D Reason: This is correct because this client has a life-threatening condition called tension pneumothorax, which requires immediate care. This client has a life-threatening condition called tension pneumothorax, which is caused by air leaking into the pleural space and compressing the lung and the heart. This can lead to respiratory failure, cardiac arrest, and death if not treated immediately. The hissing sound indicates that air is escaping from the lung through the wound. The nurse should tag this client as red, which means immediate care is needed.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today