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 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. Maintaining a low-potassium diet B. Skipping a medication dose if dizziness occurs C. Maintaining a 2 gram-sodium diet D. Drink three glasses of wine a day

Correct Answer is C

Explanation

Maintaining a 2 gram-sodium (salt) diet is an important aspect of managing hypertension. High sodium intake can contribute to elevated blood pressure. Therefore, reducing sodium intake is recommended to help control blood pressure levels. The nurse should provide guidance on reading food labels, avoiding high-sodium processed foods, and incorporating a diet rich in fruits, vegetables, and whole grains.

The other options listed are not appropriate or beneficial for managing hypertension:

Maintaining a low-potassium diet: Potassium is an essential mineral that helps regulate blood pressure. While specific potassium restrictions may be necessary for some individuals with certain medical conditions, most people with hypertension do not need to limit their potassium intake. In fact, a balanced diet with adequate potassium is generally recommended.

Skipping a medication dose if dizziness occurs: It is not advisable to skip medication doses without consulting a healthcare provider. Hypertension medications are prescribed to help control blood pressure, and missing doses can lead to uncontrolled hypertension and potential complications. If the client experiences dizziness or other side effects from the medication, they should consult their healthcare provider for appropriate management.

Drinking three glasses of wine a day: Excessive alcohol consumption can contribute to elevated blood pressure. The recommended alcohol intake for individuals with hypertension is moderate or limited to moderate levels, which typically means no more than one drink per day for women and two drinks per day for men. Drinking excessive amounts of wine or any alcoholic beverage can negatively affect blood pressure control.

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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

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