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 B

Explanation

The nurse should best follow up the assessment ﬁnding of an ankle-brachial index (ABI) of 0.40 in the right leg by implementing interventions relevant to arterial narrowing.

An ankle-brachial index is a non-invasive test used to assess peripheral arterial disease (PAD). An ABI value below 0.90 indicates signiﬁcant arterial narrowing and impaired blood ﬂow to the lower extremities. An ABI of 0.40 suggests severe arterial narrowing, which puts the client at risk for reduced perfusion and potential complications such as tissue ischemia, ulceration, and gangrene.

Implementing interventions relevant to arterial narrowing is crucial in this case. These interventions may include:

Collaborating with the healthcare provider to develop a treatment plan: This may involve prescribing medications to improve blood ﬂow, such as antiplatelet agents or vasodilators.
Encouraging lifestyle modiﬁcations: This can include smoking cessation, regular exercise, and maintaining a healthy diet low in saturated fats and high in fruits and vegetables.
Promoting optimal cardiovascular health: This can involve managing other risk factors for arterial narrowing, such as hypertension, diabetes, and high cholesterol levels.
Educating the client about the signs and symptoms of PAD: This includes teaching them to monitor for changes in skin color, temperature, and sensation in the affected limb, as well as the importance of seeking prompt medical attention if these changes occur.

Let's review the other options:

Assessing the client's use of over-the-counter dietary supplements: While it is important to assess for potential interactions between medications and dietary supplements, this would not be the immediate follow-up action for a severely reduced ABI.

Encouraging the client to increase intake of foods high in vitamin K: While maintaining a balanced diet is important for overall health, increasing vitamin K intake is not speciﬁcally indicated for addressing arterial narrowing or improving the ABI.

Adjusting the client's activity level to accommodate decreased coronary output:

Coronary output refers to blood ﬂow to the heart muscle. Arterial narrowing in the leg does not directly affect coronary output. However, it is important to encourage appropriate physical activity for the client based on their overall cardiovascular health and exercise tolerance.

A. The client reports a headache with pain at level 5 of 10 B. The client has epistaxis after blowing his nose several times C. The client has a urine output of 120 mL over a 4 hours D. The client has a new-onset blurry vision and facial asymmetry

Correct Answer is D

Explanation

The client reports a headache with pain at level 5 of 10.: While a headache can be a symptom of high blood pressure, a pain level of 5 out of 10 alone does not indicate an immediate life-threatening condition. It is important to assess and manage the client's pain, but it may not be the most critical ﬁnding to report in this situation.

The client has epistaxis after blowing his nose several times. : Epistaxis, or a nosebleed, can occur due to high blood pressure, but it is not the most urgent or critical symptom in a hypertensive emergency. While it is essential to address the nosebleed and monitor blood pressure, other symptoms may indicate more severe consequences of uncontrolled high blood pressure.

The client has a urine output of 120 mL over 4 hours.: While decreased urine output can be a concerning sign, it is not the most signiﬁcant ﬁnding to report in a hypertensive emergency. In this scenario, the focus is on acute complications related to high blood pressure, such as organ damage or impending stroke, which require immediate attention.

In summary, the ﬁnding that is most important to report to the healthcare provider in a client with a hypertensive emergency is the presence of new-onset blurry vision and facial asymmetry. These symptoms suggest potential neurological involvement and the need for urgent medical intervention to prevent serious complications like stroke.

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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

While assessing a client, the nurse notes that the client's ankle-brachial index (ABI) of the right leg is 0.40. How should the nurse best follow up this assessment ﬁnding?

Correct Answer is B

Explanation

The nurse is assessing a client with a hypertensive emergency. Which ﬁnding is most important to report to the health care provider?

Correct Answer is D

Explanation

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