A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take?

Assist the client to the orthopneic position.

Instruct the client to remain as still as possible during the recording.

Attach a blood pressure cuff to the client's upper arm.

Tell the client to expect a mild stinging sensation during the test.

Answer and Explanation

The Correct Answer is B

It is important for the client to remain still during the recording of a 12-lead ECG to obtain accurate and clear readings of the heart's electrical activity.

The orthopneic position (sitting upright and leaning forward) is typically used to help relieve shortness of breath in clients with respiratory distress and is not directly related to obtaining a 12-lead ECG.

Attaching a blood pressure cuff is not necessary for obtaining a 12-lead ECG, as it measures blood pressure and not the electrical activity of the heart.

A mild stinging sensation is not expected during the test. The electrodes used to record the ECG are typically adhesive and do not cause discomfort to the client

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Correct Answer is C

Explanation

This situation involves a medication error that could potentially harm the client, and it should be reported through an incident report.

The following examples may not require an incident report:

A nurse discovers that a client's family member has administered a PCA dose. PCA (Patient-Controlled Analgesia) is a method of pain management that allows the client to self-administer pain medication within predetermined limits. If a family member administers the PCA dose without proper authorization or understanding, it is a safety concern that should be reported.

A nurse observes a client vomiting after receiving an oral pain medication. While this situation should be assessed and managed appropriately, it does not necessarily warrant an incident report unless there are additional factors or complications involved.

A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. This situation may raise concerns regarding proper restraint removal techniques or potential safety issues, but it does not inherently indicate an immediate need for an incident report. However, if the nurse's actions were contrary to policy or posed a risk to the client's safety, it should be reported.

A. A nurse discusses a client's postoperative complications during a shift report. B. A social worker reads a client's chart as a follow-up to a requested consultation. C. A facility risk manager includes information from a client's medical record in a written report. D. A nurse tells the chaplain that a client has a new diagnosis of cancer.

Correct Answer is D

Explanation

In this scenario, the nurse disclosed sensitive medical information about the client's diagnosis to someone who is not directly involved in the client's care or treatment. This disclosure violates the client's right to privacy and confidentiality.

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A nurse is planning to obtain a 12-lead ECG for a client who has a history of cardiac dysrhythmias. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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