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 ["A","C","D"]

Explanation

Choice A reason : Dyspnea, or difficulty breathing, is a common symptom of left-sided heart failure. It occurs because the heart is unable to pump efficiently, leading to a backup of fluid in the lungs, which can cause shortness of breath.

Choice B reason : Jugular vein distention is typically associated with right-sided heart failure, not left-sided. It occurs when there is an increased pressure in the right atrium, leading to visible bulging of the neck veins.

Choice C reason : Orthopnea, or difficulty breathing while lying flat, is another symptom of left-sided heart failure. Fluid accumulation in the lungs makes it difficult for the patient to breathe without elevation, hence they may need to sleep with extra pillows.

Choice D reason : Crackles, which are heard during lung auscultation, are indicative of fluid accumulation in the alveoli due to the inefficiency of the left side of the heart to pump blood, leading to pulmonary congestion.

Choice E reason : Tachycardia, or rapid heartbeat, can be a response to left-sided heart failure as the body attempts to compensate for the decreased cardiac output by increasing the heart rate to maintain adequate blood flow.

Choice F reason : Gastrointestinal bloating is more commonly associated with right-sided heart failure due to systemic venous congestion leading to fluid accumulation in the abdominal organs and tissues.

Correct Answer is ["50"]

Explanation

Step 1 is to calculate the total drops (gtt) the nurse needs to administer. This is done by multiplying the volume of the solution (400 mL) by the drop factor (60 gtt/mL). So, 400 mL × 60 gtt/mL = 24000 gtt.

Step 2 is to calculate the total time in minutes over which the IV should be administered. Since there are 60 minutes in an hour, 8 hours is equivalent to 8 hours × 60 min/hour = 480 minutes.

Step 3 is to calculate the rate at which the IV should be administered. This is done by dividing the total drops by the total time. So, 24000 gtt ÷ 480 min = 50 gtt/min.

The nurse should set the manual IV infusion to deliver approximately 50 gtt/min.

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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 preparing to administer digoxin to a client who has left-sided heart failure. Which of the following clinical manifestations should the nurse expect to see in this client? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

Correct Answer is ["50"]

Explanation

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