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 ["B","D","E"]

Explanation

A. Elevated temperature: Elevated temperature is not typically associated with advanced COPD unless there is an underlying infection. Infections such as pneumonia may exacerbate COPD symptoms but are not universal findings in advanced COPD.

B. Pursed-lip breathing: Pursed-lip breathing is a common compensatory mechanism seen in clients with COPD. It helps to slow down the rate of expiration and prevents alveolar collapse, improving gas exchange.

C. Clubbing of the fingers: Clubbing of the fingers is not typically associated with COPD. It is more commonly seen in conditions such as chronic hypoxemia, congenital heart disease, and certain lung diseases like bronchiectasis.

D. Concave chest: In advanced COPD, the chest may appear hyperinflated with a barrel-shaped chest due to air trapping. The presence of a concave chest is not characteristic of COPD.

E. Dyspnea at rest: Dyspnea, or difficulty breathing, is a hallmark symptom of COPD. In advanced stages, clients may experience dyspnea even at rest due to severe airflow limitation and impaired gas exchange.

A. Wheezing in all lung fields. B. Pitting edema in bilateral lower extremities. C. Oral fluid intake of 2000 mL in 24 hours. D. Significant fatigue for more than one month.

Correct Answer is B

Explanation

A. Wheezing in all lung fields may indicate respiratory issues but does not directly support the diagnosis of Excess Fluid Volume.
B. Pitting edema in bilateral lower extremities is a classic sign of fluid overload, which directly supports the diagnosis of Excess Fluid Volume.

C. An oral fluid intake of 2000 mL in 24 hours is within normal limits for an adult and does not necessarily indicate Excess Fluid Volume without other symptoms.
D. Significant fatigue for more than one month could be related to a variety of conditions and is too nonspecific to support the diagnosis of Excess Fluid Volume without additional assessment data.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with advanced COPD. The nurse should anticipate which assessment findings when caring for clients with advanced COPD? (Select all that apply.)

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

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Correct Answer is B

Explanation

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