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 C

Explanation

Based on the information provided, an Ankle-Brachial Index (ABI) of 0.89 indicates a mild reduction in blood flow to the lower extremities, suggesting peripheral arterial disease (PAD). In this case, the nurse should educate the client about the use of compression stockings.

Compression stockings are a conservative management approach for peripheral arterial disease. They help improve blood flow and alleviate symptoms by applying pressure to the legs, promoting venous return, and reducing swelling. Educating the client about the use of compression stockings can help improve circulation and manage symptoms such as pain, cramping, and fatigue.

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

Document the information as a normal finding: An ABI of 0.89 indicates an abnormal finding suggestive of peripheral arterial disease. It should not be documented as a normal finding, as it requires further assessment and intervention.

Prepare the client for an arterial bypass: An arterial bypass is a surgical intervention that is typically reserved for more severe cases of peripheral arterial disease. With an ABI of 0.89, which indicates mild reduction in blood flow, arterial bypass is not the first-line intervention. Conservative measures and medical management are usually recommended initially.

Anticipate a prescription for clopidogrel and simvastatin: Medications like clopidogrel (antiplatelet) and simvastatin (statin) may be prescribed for peripheral arterial disease. However, the next appropriate step after obtaining an ABI of 0.89 would be to educate the client about the use of compression stockings as a conservative management option before considering medication therapy.

A. "I will not take this medicine when my blood pressure is okay" B. "I will check blood pressure in both arms and legs before taking the drug." C. "I will decrease potassium foods such as bananas in my diet." D. "I will take this medication in the morning since I will be urinating more."

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.

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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 assessing a client with a presumptive diagnosis of peripheral arterial disease. The nurse obtains an Ankle-Brachial index of 0.89. Which intervention should the nurse take next?

Correct Answer is C

Explanation

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

Correct Answer is D

Explanation

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