A nurse supervises assistive personnel (AP) applying electrocardiographic monitoring. Which statement would the nurse provide to the AP related to this procedure?
“Turn off oxygen prior to monitoring the client.”
“Add gel to the electrodes prior to applying them.”:
“Clean the skin and clip hairs if needed.”
“Place the electrodes on the posterior chest”.
The Correct Answer is C
A. “Turn off oxygen prior to monitoring the client.”: It is unnecessary and unsafe to turn off supplemental oxygen when applying ECG electrodes; oxygen should remain on to maintain adequate oxygenation.
B. “Add gel to the electrodes prior to applying them.”: Modern ECG electrodes are pre-gelled, so adding extra gel is not required and may interfere with electrode adhesion or signal quality.
C. “Clean the skin and clip hairs if needed.”: Proper skin preparation, including cleaning and hair removal, ensures good electrode contact and accurate ECG readings. This is the correct step that the AP should follow.
D. “Place the electrodes on the posterior chest”: Standard ECG electrode placement is on the anterior chest and limbs; posterior placement is not part of routine 12-lead ECG monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Perform immediate defibrillation: Defibrillation is indicated for pulseless ventricular tachycardia or ventricular fibrillation. Since this client has a pulse and is hemodynamically stable, defibrillation is not appropriate.
B. Administer adenosine 6 mg IVP: Adenosine is the first-line treatment for stable SVT. Administering a rapid IV push of 6 mg is the initial step per hospital dysrhythmia protocols to terminate the arrhythmia safely while the client remains stable.
C. Perform immediate cardioversion: Synchronized cardioversion is reserved for clients with SVT who are unstable (e.g., hypotension, chest pain, altered mental status). This client is stable, so cardioversion is not the first action.
D. Administer adenosine 12 mg IVP: A 12 mg dose of adenosine is used only if the initial 6 mg dose is ineffective. The protocol starts with 6 mg first, making 12 mg premature as the initial intervention.
Correct Answer is B
Explanation
A. Placing the patient in Trendelenburg position: Trendelenburg position does not correct hyponatremia or relieve confusion. It is primarily used to manage hypotension and would not address the neurological symptoms caused by low sodium.
B. Measuring intake and output every shift: Monitoring fluid balance helps prevent further dilutional hyponatremia and allows the healthcare team to manage fluid restrictions or replacements appropriately. Accurate I&O tracking is essential for preventing worsening confusion related to electrolyte imbalance.
C. Increase the lactated ringer IV flow rate to 100 mL/hr: Increasing isotonic fluid without provider orders may worsen hyponatremia or fluid overload. Fluid therapy must be carefully managed based on serum sodium levels and clinical status.
D. Administering mannitol as prescribed by the physician: Mannitol is an osmotic diuretic used to reduce intracranial pressure, not to correct hyponatremia. It would not directly relieve confusion caused by low sodium levels and could complicate fluid and electrolyte balance.
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