A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?

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.

Choice A: Ask the client to shrug his shoulders against passive resistance is not an assessment that will give the nurse information about the function of cranial nerve III. This assessment will test the function of cranial nerve XI, which is the accessory nerve. The accessory nerve innervates the trapezius and sternocleidomastoid muscles, which are involved in shoulder and neck movements.

Choice B: Instruct the client to look up and down without moving his head is an assessment that will give the nurse information about the function of cranial nerve III. Cranial nerve III is the oculomotor nerve, which innervates four of the six extraocular muscles that control eye movements. The oculomotor nerve also controls pupil size and lens shape. By instructing the client to look up and down without moving his head, the nurse can assess the ability of the oculomotor nerve to move the eyes vertically and adjust to different distances.

Choice C: Observe the client's ability to smile and frown is not an assessment that will give the nurse information about the function of cranial nerve III. This assessment will test the function of cranial nerve VII, which is the facial nerve. The facial nerve innervates the muscles of facial expression, which are involved in smiling, frowning, blinking, and other facial movements.

Choice D: Have the client stand with his eyes closed and touch his nose is not an assessment that will give the nurse information about the function of cranial nerve III. This assessment will test the function of cranial nerve VIII, which is the vestibulocochlear nerve. The vestibulocochlear nerve innervates the inner ear and is responsible for hearing and balance. By having the client stand with his eyes closed and touch his nose, the nurse can assess the ability of the vestibulocochlear nerve to maintain equilibrium and coordination.