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 D
Explanation
Choice A Reason: This is incorrect. Opioids are not indicated for a client who is emerging from a coma, as they can cause respiratory depression, sedation, and confusion. They may also mask the signs of increased intracranial pressure or neurological deterioration.
Choice B Reason: This is incorrect. Darkening the room may not be helpful for a client who is emerging from a coma, as it may increase their disorientation and agitation. The nurse should provide adequate lighting and orient the client to time, place, and person frequently.
Choice C Reason: This is incorrect. Applying restraints may worsen the restlessness and agitation of a client who is emerging from a coma, as they may perceive them as a threat or a restriction. Restraints may also increase the risk of injury, infection, or skin breakdown. The nurse should use restraints only as a last resort and with a physician's order.
Choice D Reason: This is correct. Reducing stimuli is an appropriate intervention for a client who is emerging from a coma, as it can help calm them and prevent sensory overload. The nurse should limit noise, visitors, and unnecessary procedures, and provide a quiet and comfortable environment.
Correct Answer is A
Explanation
Choice A: Troponin I is a laboratory test that the nurse should anticipate the provider to prescribe. Troponin I is a protein that is released into the blood when the heart muscle is damaged. Troponin I levels are elevated in clients who have acute myocardial infarction (AMI), which is a heart atack caused by a blockage of blood flow to the heart. Chest pressure and shortness of breath are common signs and symptoms of AMI. Troponin I is a specific and sensitive marker of cardiac injury and can help diagnose AMI and guide treatment.
Choice B: Aspartate aminotransferase (AST) is not a laboratory test that the nurse should anticipate the provider to prescribe. AST is an enzyme that is found in various tissues, such as the liver, heart, skeletal muscle, and kidneys. AST levels are elevated in clients who have liver damage, hepatitis, cirrhosis, or alcohol abuse. AST levels can also be elevated in clients who have AMI, but they are not as specific or sensitive as troponin I. AST is not a reliable indicator of cardiac injury and can be influenced by other factors.
Choice C: B-type natriuretic peptide (BNP) is not a laboratory test that the nurse should anticipate the provider to prescribe. BNP is a hormone that is secreted by the heart when it is stretched or overloaded. BNP levels are elevated in clients who have heart failure, which is a condition in which the heart cannot pump enough blood to meet the
body's needs. Shortness of breath can be a sign of heart failure, but chest pressure is not. BNP is not a specific or sensitive marker of cardiac injury and can be influenced by other factors.
Choice D: Lipase is not a laboratory test that the nurse should anticipate the provider to prescribe. Lipase is an enzyme that is produced by the pancreas and helps digest fats. Lipase levels are elevated in clients who have pancreatitis, which is an inflammation of the pancreas. Pancreatitis can cause abdominal pain, nausea, vomiting, and fever. Chest pressure and shortness of breath are not signs of pancreatitis. Lipase is not a specific or sensitive marker of cardiac injury and has no relation to AMI.
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