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?

Use alcohol swabs to clean the skin before applying the leads

Clip the chest hair with the patient's permission before applying the leads

Apply the leads to the arms and legs only

Reschedule the ECG

Answer and Explanation

The Correct Answer is B

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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Correct Answer is A

Explanation

Based on the information provided, the nurse should anticipate that the medical treatment prescribed for a client with an abdominal aortic aneurysm less than 3 cm in size would be regular ultrasound screenings every six (6) months.

Monitoring the size of the abdominal aortic aneurysm through ultrasound is a common approach for managing small aneurysms. Regular ultrasound screenings allow healthcare providers to track the growth rate of the aneurysm and determine if any intervention, such as surgical repair, is necessary as the aneurysm progresses in size.

Let's review the other options and explain why they are not the most appropriate treatments for an abdominal aortic aneurysm less than 3 cm in size:

Intravenous pyelogram yearly: An intravenous pyelogram is an imaging test used to evaluate the urinary system, specifically the kidneys, ureters, and bladder. It is not directly related to the management or monitoring of an abdominal aortic aneurysm.

Assessment of abdominal girth monthly: Assessing the abdominal girth may be a part of the overall assessment of the client's condition, but it is not the primary treatment for managing an abdominal aortic aneurysm. Monitoring the aneurysm size through regular ultrasound screenings is a more specific and accurate approach.

Repair of abdominal aortic aneurysm: Repair of an abdominal aortic aneurysm is typically indicated when the aneurysm reaches a certain size threshold or if it poses a high risk of rupture. For an aneurysm less than 3 cm in size, repair is usually not the initial treatment option. Instead, regular monitoring through ultrasound screenings is recommended to assess the aneurysm's growth rate and determine the appropriate time for intervention.

A. Assess pulse of affected extremity every 15 minutes at ﬁrst. B. Palpate the affected leg for pain during every assessment C. Assess the client for signs and symptoms of compartment syndrome every 2 hours. D. Perform Doppler evaluation once daily.

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

Explanation

Assess pulse of the affected extremity every 15 minutes at ﬁrst: Frequent assessment of the pulse in the affected extremity is important to monitor for any changes in blood ﬂow. This allows the nurse to identify any potential complications such as graft occlusion or compromised circulation promptly.

Palpate the affected leg for pain during every assessment: Assessing for pain in the affected leg is crucial to identify any signs of ischemia or inadequate perfusion. Increased pain could indicate reduced blood ﬂow or other complications that require immediate attention.

Assess the client for signs and symptoms of compartment syndrome every 2 hours: Compartment syndrome can occur after vascular surgeries, and early recognition is vital. The nurse should assess for signs and symptoms such as pain, numbness, tingling, increased swelling, and tense compartments. Regular assessment every 2 hours can help detect compartment syndrome promptly and prevent further complications.

Perform Doppler evaluation once daily: Doppler evaluation may be ordered by the healthcare provider to assess blood ﬂow and graft patency. However, the frequency of Doppler evaluation may vary depending on the client's condition and the healthcare provider's orders. Once daily assessment is not suﬃcient if there are concerns regarding blood ﬂow or graft viability.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing the medical electronic record of a client with abdominal aortic aneurysm less than 3 cm in size. Which medical treatment should the nurse anticipate to be prescribed for the client?

Correct Answer is A

Explanation

A client who has undergone a femoral to popliteal bypass graft surgery returns to the surgical unit. Which assessments should the nurse perform during the ﬁrst postoperative day?

Correct Answer is ["A","B","C","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?

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