A nurse is assisting with obtaining an electrocardiogram (ECG) for a client who has atrial fibrillation. Which of the following actions should the nurse take? (Select all that apply.)
Inspect the electrode pads
Instruct the client not to talk during the test
Administer an analgesic prior to the procedure
Wash the skin with plain water before placing the electrodes
Keep the client NPO after midnight
Correct Answer : A,B
Choice A: Inspecting the electrode pads is an action that the nurse should take. The electrode pads are adhesive patches that atach to the skin and connect to the ECG machine. The nurse should inspect the electrode pads for expiration date, cleanliness, and stickiness, and replace them if necessary. The nurse should also check for any signs of skin irritation or allergy from the electrode pads.
Choice B: Instructing the client not to talk during the test is an action that the nurse should take. Talking during the test can interfere with the ECG recording and cause artifacts or false readings. The nurse should instruct the client to remain still and quiet during the test, and avoid any movements or activities that can affect the heart rate or rhythm, such as coughing, deep breathing, or shivering.
Choice C: Administering an analgesic prior to the procedure is not an action that the nurse should take. An analgesic is a pain reliever that can be given orally, intravenously, or topically. An analgesic is not necessary for an ECG, as it is a noninvasive and painless procedure. An analgesic can also alter the heart rate or rhythm and affect the ECG results. The nurse should only administer an analgesic if prescribed by the provider for another reason.
Choice D: It is more common to use alcohol swabs, and not water, to clean the skin as they are better at removing oils and ensuring good adhesion of the electrodes.
Choice E: Keeping the client NPO after midnight is not an action that the nurse should take. NPO means nothing by mouth, which is a restriction of food and fluids before certain procedures or surgeries. NPO is not required for an ECG, as it does not involve any anesthesia or sedation. The nurse should allow the client to eat and drink normally before and after the test, unless instructed otherwise by the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect. Sinus bradycardia is a slow and regular heart rate that originates from the sinus node. It does not cause irregular palpitations, fatigue, or dizziness, unless the heart rate is very low or the client has underlying cardiac disease.
Choice B reason: This is incorrect. Sinus tachycardia is a fast and regular heart rate that originates from the sinus node. It may cause fatigue or dizziness, but not irregular palpitations or pulse deficit.
Choice C Reason: This is correct. Atrial fibrillation is a fast and irregular heart rate that originates from multiple foci in the atria. It causes irregular palpitations, fatigue, dizziness, and pulse deficit due to ineffective atrial contractions and variable ventricular response.
Choice D Reason: This is incorrect. First-degree AV block is a delay in the conduction of impulses from the atria to the ventricles. It does not affect the heart rate or rhythm, and does not cause any symptoms.
Correct Answer is D
Explanation
The correct answer is D. Blood pressure 115/68 mm Hg.
Choice A reason: Heart rate 180/min is incorrect because, although an increased heart rate is a compensatory mechanism, a rate of 180/min is excessively high and suggests a more severe stage of shock or other cardiac issues.
Choice B reason: Mottled skin is incorrect as it indicates poor perfusion seen in decompensated shock, where organ dysfunction begins to manifest, not in the compensatory stage.
Choice C reason: Hypokalemia, or low potassium levels, is incorrect because electrolyte imbalances are not typically a finding in the compensatory stage of shock. Normal potassium levels range from 3.5 to 5.0 mEq/L.
Choice D reason: Blood pressure 115/68 mm Hg is correct because it falls within the normal blood pressure range, which the body strives to maintain during the compensatory stage of shock through various mechanisms.
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