The nurse is caring for a client scheduled for a cardiac stress test at 1100. When the nurse enters the client's room at 0800, the client requests toast or at least some coffee. What is the best response?

Explain that no food or drink is allowed for 4 hours before the stress test.

Ask the client's visitor to bring some coffee from the cafeteria for the client.

Make up a small breakfast tray from what is available on the unit.

Offer hot tea or coffee only.

Answer and Explanation

The Correct Answer is A

The best response by the nurse would be to explain that no food or drink is allowed for 4 hours before the stress test.

The reason for this restriction is that consuming food or drink can affect the accuracy of the cardiac stress test results. Eating or drinking can increase heart rate and blood pressure, potentially altering the test's interpretation. It is important for the client to have an empty stomach to ensure accurate test results.

Let's review the other options and explain why they are not the best responses:

Asking the client's visitor to bring some coffee from the cafeteria for the client: This option goes against the restriction of no food or drink before the stress test. It is important to adhere to the guidelines provided to ensure accurate test results.

Making up a small breakfast tray from what is available on the unit: Similarly, providing breakfast to the client goes against the restriction of no food before the stress test. The client should have an empty stomach for the test.

Offering hot tea or coffee only: While hot tea or coffee might be tempting for the client, it still violates the requirement of no food or drink before the stress test. The client should only be allowed to consume water during the fasting period.

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Correct Answer is D

Explanation

Hydrochlorothiazide is a diuretic medication commonly prescribed for hypertension. It works by increasing urine output, which helps to reduce ﬂuid volume and lower blood pressure. Taking the medication in the morning is beneﬁcial because the increased urine production during the day can help prevent nighttime disruptions due to frequent urination.

Let's go through the other statements and explain why they are not accurate:

"I will not take this medicine when my blood pressure is okay":

This statement indicates a misunderstanding about the purpose of hydrochlorothiazide. It is important to take prescribed medications consistently, even when blood pressure readings are within the normal range, as they are intended to help maintain blood pressure control.

"I will check blood pressure in both arms and legs before taking the drug":

Checking blood pressure in both arms and legs is not directly related to hydrochlorothiazide use. Blood pressure should be monitored regularly, but it is not necessary to perform these measurements speciﬁcally before taking the medication.

"I will decrease potassium foods such as bananas in my diet":

Hydrochlorothiazide can cause potassium loss as a side effect. However, reducing potassium-rich foods without healthcare provider guidance may not be appropriate. It is important for the client to discuss dietary adjustments and potassium supplementation with their healthcare provider if needed.

A. Use alcohol swabs to clean the skin before applying the leads B. Clip the chest hair with the patient's permission before applying the leads C. Apply the leads to the arms and legs only D. Reschedule the ECG

Correct Answer is B

Explanation

The most appropriate nursing intervention to improve adhesion of the ECG leads on a male client with abundant chest hair is to clip the chest hair with the patient's permission before applying the leads. Chest hair can interfere with the adhesion of the ECG leads, resulting in poor signal quality and potentially affecting the accuracy of the ECG recording. By clipping the chest hair, the nurse can improve the contact between the skin and the ECG leads, allowing for better adhesion and signal transmission.

It is important to obtain the patient's permission before clipping the chest hair to respect their autonomy and ensure their comfort during the procedure. The nurse should explain the reason for clipping the hair and address any concerns or questions the patient may have.

Let's review the other options and explain why they are not the most appropriate interventions:

Using alcohol swabs to clean the skin before applying the leads: While cleaning the skin with alcohol swabs is a routine practice to remove oils and dirt that can affect adhesion, it may not be sufficient in the presence of abundant chest hair. Clipping the hair would be more effective in this situation.

Applying the leads to the arms and legs only: This option would not provide an accurate 12-lead ECG recording, as the chest leads are essential for evaluating the electrical activity of the heart from different angles. It is important to have the leads properly placed on the chest for an accurate assessment.

Rescheduling the ECG: Unless there are other valid reasons for rescheduling, such as a medical condition that contraindicates the procedure, rescheduling solely due to abundant chest hair would be unnecessary. Clipping the hair is a practical and effective solution to improve adhesion.

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The nurse is caring for a client scheduled for a cardiac stress test at 1100. When the nurse enters the client's room at 0800, the client requests toast or at least some coffee. What is the best response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a hypertensive client who is taking hydrochlorothiazide. What client statement indicates understanding about hydrochlorothiazide?

Correct Answer is D

Explanation

The nurse is performing a 12-lead ECG on a male client with abundant chest hair. What is the most appropriate nursing intervention to improve adhesion of the ECG leads?

Correct Answer is B

Explanation

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