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

Defibrillation is not the first-line treatment for atrial fibrillation. It is used to treat life-threatening cardiac arrhythmias such as ventricular fibrillation or pulseless ventricular tachycardia. Atrial fibrillation, on the other hand, is a rapid and irregular atrial rhythm, and defibrillation is not indicated for its treatment.

Obtain consent for transesophageal echocardiogram (TEE): This is an appropriate action for a client with atrial fibrillation. A TEE is often performed to assess the structure and function of the heart in cases of atrial fibrillation, especially when considering cardioversion or other interventions.

Obtain consent for cardioversion: Cardioversion is a common treatment option for atrial fibrillation, especially when the client is unstable or experiencing symptoms. It involves restoring a normal heart rhythm through the use of electrical shocks or medications. It is important to obtain informed consent before performing cardioversion, but this does not necessarily require questioning.

Hold digoxin 48 hours prior to cardioversion: Digoxin is commonly held before cardioversion because it can increase the risk of certain arrhythmias during the procedure. This is a standard precaution to minimize potential adverse effects. Therefore, the nurse does not need to question this action, as it aligns with established guidelines.

A. A client with a blood pressure of 190/92 mm Hg who reports chest pain B. A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia C. A client with a blood pressure of 178/90 mm Hg who has intermittent claudication D. A client with a blood pressure of 172/98 mm Hg scheduled for a stress test

Correct Answer is A

Explanation

The nurse should assess the client with a blood pressure of 190/92 mm Hg who reports chest pain ﬁrst. Chest pain can be a symptom of myocardial ischemia or a heart attack, which requires immediate attention. The combination of high blood pressure and chest pain is concerning and may indicate acute coronary syndrome. Prompt assessment and intervention are crucial to evaluate the cause of the chest pain and initiate appropriate treatment.

A client with a blood pressure of 190/104 mm Hg who has sinus tachycardia: While sinus tachycardia may indicate increased heart rate, it does not necessarily require immediate assessment unless other concerning symptoms are present. However, the nurse should address the elevated blood pressure in a timely manner.

Intermittent claudication refers to leg pain or discomfort during physical activity due to reduced blood ﬂow. While it is important to assess and manage this symptom, it is not typically considered an urgent condition requiring immediate assessment compared to chest pain.

The client scheduled for a stress test may have elevated blood pressure, but if they are stable and not currently experiencing symptoms, they may not require immediate assessment compared to a client with chest pain.

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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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