A nurse is preparing to perform a 12-lead electrocardiogram. Which of the following instructions should the nurse provide to the client while applying the electrode gel pads?

"I will be placing electrodes on your breasts."

"I will lower the head of your bed so you can lie flat."

"Relax and try not to move or speak once I have attached the gel pads."

"Try to hold your breath until this procedure is complete."

Answer and Explanation

The Correct Answer is C

A. "I will be placing electrodes on your breasts": This statement is incorrect and may cause unnecessary concern or discomfort for the client. Electrodes for a 12-lead electrocardiogram are typically placed on the chest, not the breasts.

B. "I will lower the head of your bed so you can lie flat": This statement may be relevant for certain procedures but is not specific to applying electrode gel pads for a 12-lead electrocardiogram.

C. "Relax and try not to move or speak once I have attached the gel pads": This instruction is essential for obtaining a clear and accurate electrocardiogram recording. Movement or talking during the procedure can interfere with the quality of the tracing.

D. "Try to hold your breath until this procedure is complete": This instruction is unnecessary and could cause discomfort or anxiety for the client. There is no need for the client to hold their breath during a standard electrocardiogram procedure.

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

Explanation

A. Confusion and restlessness: Confusion and restlessness can indicate changes in cerebral perfusion as the body begins to shut down. These signs may occur as death approaches.

B. Increased appetite and thirst: Increased appetite and thirst are less likely as death approaches.

In fact, clients often have decreased appetite and thirst as the body's systems slow down.

C. Increase in urinary and bowel output: As death approaches, urinary and bowel output typically decrease as the body's metabolic processes slow down.

D. Increased fatigue and sleep: Increased fatigue and sleepiness are common as death approaches. The body's energy levels decrease, leading to increased periods of sleep and rest.

E. Excess secretions in the throat and decrease swallow reflex: Excess secretions in the throat and a decrease in the swallow reflex can occur as the body's ability to manage secretions diminishes. This can lead to a gurgling sound in the throat known as the death rattle.

A. Heart rate of 90 bpm. B. Blood pressure of 96/50 mm Hg. C. Urine output of 2 mL/kg per hour D. Pain rating of 7 on a 1 to 10 point scale.

Correct Answer is B

Explanation

A. Heart rate of 90 bpm: While an elevated heart rate may be expected in response to burn injury and the body's stress response, a heart rate of 90 bpm alone may not be concerning without additional context.

B. Blood pressure of 96/50 mm Hg: This blood pressure reading indicates hypotension, which can be a sign of inadequate tissue perfusion, fluid loss, or shock. It requires prompt notification of the healthcare provider for further assessment and intervention.

C. Urine output of 2 mL/kg per hour: Adequate urine output is important for renal function and fluid balance, and a urine output of 2 mL/kg per hour is within the normal range. While changes in urine output should be monitored, this finding alone does not require immediate notification of the healthcare provider.

D. Pain rating of 7 on a 1 to 10 point scale: Pain management is important in burn care, but a pain rating of 7 on a 1 to 10 scale is not unusual in clients with burns and may not require immediate notification of the healthcare provider unless accompanied by other concerning symptoms.

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A nurse is preparing to perform a 12-lead electrocardiogram. Which of the following instructions should the nurse provide to the client while applying the electrode gel pads?

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