A nurse is preparing to perform a 12-lead electrocardiogram (ECG). Which of the following instructions should the nurse provide to the client?

"I will be placing some electrodes on your chest and extremities."

"Be sure to remain still once I have attached the gel pads."

"You might feel some slight pressure during the procedure."

"The test will be complete in a few minutes."

Answer and Explanation

The Correct Answer is A

Choice A reason : This instruction is accurate because for a standard 12-lead ECG, electrodes are placed on the patient's chest and extremities to record the electrical activity of the heart. The placement of these electrodes is crucial for accurate readings and diagnosis. The electrodes do not emit electricity; they merely record and measure the electrical activity in your heart, providing essential information to the medical provider.

Choice B reason : Remaining still during an ECG is important to prevent artifacts that can interfere with the interpretation of the heart's electrical activity. Movement can cause the readings to be inaccurate, which is why patients are advised to remain still once the electrodes are in place.

Choice C reason : While the client might feel some pressure from the electrodes, the term 'tingling' is not accurate as the ECG is a painless procedure. The electrodes may cause mild irritation upon the skin, but there is otherwise no sensation associated with the test itself.

Choice D reason : The duration of the test is indeed short, typically only a few minutes, but this is not the primary instruction. The nurse should first inform the client about the electrode placement, which is essential for the procedure. The ECG will only take a few minutes in total once the procedure is underway, not counting equipment set-up time.

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Correct Answer is ["B","C","E"]

Explanation

Choice A reason : Documenting the frequency of blood pressure measurements is crucial for monitoring trends and identifying any changes that may indicate a health issue. It helps in assessing the effectiveness of interventions and in making informed clinical decisions.

Choice B reason : Recording the interventions implemented in response to a high blood pressure reading is important for continuity of care. It ensures that all healthcare providers are aware of the actions taken and can evaluate their effectiveness.

Choice C reason : Noting the patient's response to interventions provides insight into the efficacy of the treatment plan. It is essential for adjusting care plans and for healthcare providers to understand the patient's progress.

Choice D reason : Identifying the person who obtained the blood pressure reading is a part of proper documentation practices. It allows for accountability and follow-up if there are any questions or concerns about the reading.

Choice E reason : The site where the blood pressure was taken can affect the reading. Documenting this information helps to ensure that readings are consistent and comparable over time. It is also important in case an alternative site needs to be used in future measurements.

A. "Both heparin and warfarin work together to dissolve the clots." B. "Heparin enhances the effects of the warfarin." C. "I will ask the charge nurse to call your provider and get an explanation." D. "Heparin will be continued until the warfarin reaches a therapeutic level."

Correct Answer is D

Explanation

Choice A reason : This statement is incorrect because neither heparin nor warfarin dissolves clots. They prevent the formation of new clots and the growth of existing clots.

Choice B reason : This statement is not accurate. Heparin and warfarin do not enhance each other's effects. They work in different pathways of the clotting cascade. Heparin acts quickly, whereas warfarin takes several days to reach therapeutic levels.

Choice C reason : While seeking clarification from a provider is a part of good nursing practice, it is not the most informative response for the client. The nurse should provide education based on their knowledge and available information.

Choice D reason : This is the correct response. Heparin acts quickly and is used to stabilize the patient while waiting for warfarin to reach therapeutic levels, which is monitored by the international normalized ratio (INR) and usually takes several days.

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A nurse is preparing to perform a 12-lead electrocardiogram (ECG). Which of the following instructions should the nurse provide to the client?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with teaching a class about documenting blood pressure. The nurse should include documenting which of the following information?

Correct Answer is ["B","C","E"]

Explanation

Correct Answer is D

Explanation

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