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NCLEX Cardiac

Subjects : nclex, health-sciences, nursing

Instructions:

Answer 50 questions in 15 minutes.
If you are not ready to take this test, you can study here.
Match each statement with the correct term.
Don't refresh. All questions and answers are randomly picked and ordered every time you load a test.

This is a study tool. The 3 wrong answers for each question are randomly chosen from answers to other questions. So, you might find at times the answers obvious, but you will see it re-enforces your understanding as you take the test each time.

1. Where should you place your stethescope to find the mitral (apex) valve?
Fifth left intercostal space medial to the midclavicular line.
Chronic arteriosclerotic disease.
Smoking - elevated cholesterol - diabetes - hypertension - old age - and family hx of coronary artery disease.
Idiopathic

2. What should you remember while taking care of someone with a peripheral arterial occlusion?
Stroke - renal or heart failure - paraplegia secondary to compromised blood flow - or death from aortic rupture.
Use sterile gloves and aseptic technique - clean skin over port with alcohol or iodine - insert a 21 or 22 gauge HUBER needle (noncoring - won't break apart) attached to syringe or tubing into the middle of the port until rigid back of port is palpab
NO TED HOSE - NO SHEETS/BLANKETS - NO COMPRESSION DEVICES - (TEACH NO OPEN TOES SHOES). Lambs wool is okay!
Using both gloved hands - apply firm pressure just above the skin puncture site and over the hematoma to compress the area. Wait at least 15 mins before removing pressure and reassessing the site. Then notify the health care provider.

3. In what locations should you not place electrodes?
In fatty areas or over major muscles - large breasts - or bony prominences.
Ask patient to make a tight fist - using your index and middle fingers compress both the radial and ulnar arteries to obstruct blood flow to hand - ask pt to relax hand (hand and palm should appear blanched bc flow stopped) - release pressure on ulna
Decreased tissue perfusion. Tx: clot busting treatment must start within 6 hours.
Open up blood vessels

4. What is the goal of treatment for an MI? Treatment?
Pulse before and after giving.
ST segment elevation (STEMI)
Limit the size of the infarction is the goal. Treatment= thrombolytic therapy (tPA) initiated within 6 hours of the first symptoms= standard treatment.
Second left intercostal space

5. When should a patient call their doctor after having an implantable cardioverter defibrillator (ICD) placed?
Deep in the sternomastoid muscle - so look for pulsations in the soft tissue surrounding that area.
It is calculated by checking the brachial BP and the ankle BP. The ankle systolic pressure is divided by the brachial systolic. The NA can perform. 0.97-1 is normal anything below indicates ischemia.
Second Right intercostal space.
If feel more than 3 shocks in a row or develop signs of infection at the site.

6. What should you do if the PT value is 45 sec?
Don a protective gown - gloves - and goggles - call Dr - hand pt. emesis basin and raise the HOB 45* (at this angle he can spit out blood and prevent N&V/aspiration - have another nurse firmly press on his nose just below bony part (apply pressure at
Assess and mark the location of the dorsalis pedis and posterior tibial pulses in affected leg - wash hands and put on sterile gloves - gown - and mask - position device - check circulation and make sure good pedal pulse is present - IMMEDIATELY REPO
Nitrates - Beta blockers - and Calcium channel blockers
D/C the med and call the doctor.

7. What is a major complication of central line placement?
Check for response - activate ERS - open airway head tilt chin lift - check breathing (5-10 sec) - give 2 breaths (1 sec) with visible chest rise - checks brachial pulse (5-10 sec) - locates CPR finger position - deliver 1st cycle of compressions (30
Used to detect an abdominal aortic aneurysm. This noninvasive test takes 15 to 30 mins. They apply conductive gel to your abdomen and move a transducer over abdomen to scan blood vessels. Sound waves bouncing off anatomic structures are translated in
0.5-2.0 ng/ml
Pneumothorax and will end up with chest tube to help reinflate lung.

8. What is epistaxis?
A nosebleed
Steroid treatment or a pregnant woman who is retaining water.
Feeling of fullness in head - tightness around shirt collar - or rings/jewelry that suddenly seem tight - swelling in face - hands - arms - and swollen/cyanotic lips - dyspnea - coughing - hoarseness - chest pain - hemotysis - visable collateral ches
Hair loss - muscle mass loss - pallor when elevated - dependent rubor - and prolonged cap refill time.

9. What does a swan ganz measure?
BIRTH CONTROL PILL (LEADING CAUSE of HTN In YOUNG WOMEN-45=STILL YOUNG) - BLACK Male (then white male - than black female - then white female) - obesity - smoking - stress - high Na diet - lack of exercise - age - sex - race - or noncompliance.
Changing the way that you live is the first step. STOP SMOKING!!!! <30% FAT In DIET (don't avoid all fat) - lose weight - exercise - limit salt intake - nitro - Angioplasty (stent insertion) or CABG.
Chest pain or discomfort that occurs when your heart doesn't get enough blood and oxygen. Stable: the feeling comes and goes at expected times. Unstable: the pattern of your pain has changed (longer - hurts more - etc.)
The right and left ventricular pressures - cardiac output - arterial venous O2 difference - and pulmonary artery pressure.

10. Without prompt surgery for an aortic dissection What is someone at risk for developing?
A central line placed that measures the right atrial pressure. Normal= 4-10 cm of H20.
RAndI= Razor - electric - Aspirin - NO - Needles - small gauge - Decrease - needle sticks - and Injury- protect from. No percodan or NSAIDS - no open toed shoes.
Idiopathic
Stroke - renal or heart failure - paraplegia secondary to compromised blood flow - or death from aortic rupture.

11. What is the nursing care associated with chemical stress tests (persantine stress test)?
This noninvasive test takes 24 hours and causes no discomfort. Electrodes are applied to your body - you need to log your activities for a 24 hour period (walking - sleeping - urinating - physical symptoms - and medications). Don't tamper with the mo
Explain procedure - stress importance of reporting symptoms. INSTRUCT The PATIENT NO TO EAT DRINK OR SMOKE AT LEAST 1 HOUR BEFORE The TEST. EVALUATE PATIENTS HISTORY FOR ANY CARDIAC CONDITIONS OR MEDICATIONS THAT MAY INTERFERE WITH The TEST!!! (No va
Hematuria (tea or coca cola colored) - nosebleeds - gingival bleeding (no medicated mouth wash - flossing - or lemon glycerin swabs) - and bruising (assess for abuse w/o caregiver).
Right atrium - TRICUSPID VALVE (tissue) - right ventricle - PULMONIC VALVE (paper) - lungs - left atrium - MITRAL VALVE (My) - left ventricle - AORTIC VALVE (Assets). Tissue PAPER MY ASSETS!

12. What is an acute peripheral arterial occlusion?
A central line placed that measures the right atrial pressure. Normal= 4-10 cm of H20.
When they occur >6 per minute or occurring 2 or more in a row (bigeminy or trigeminy=on way out).
Put on gloves - remove the previous application paper and use a tissue to remove all ointment from the site to prevent overdose - squeeze the prescribed ointment in a thin layer onto a clean ruled application paper - choose an unused site on the ches
The arteries have narrowed - decreased O2 to tissues= hypoxia to cells.

13. What should you teach your patient about MRI?
MRI is painless - you must remain still inside a small/noisy space. If you are claustrophobic you may need sedation. Remove all jewelry and other metal objects. If you have any shrapnel - a pacemaker - or any surgically implanted joints - pins - clip
Cannot
Use sterile gloves and aseptic technique - clean skin over port with alcohol or iodine - insert a 21 or 22 gauge HUBER needle (noncoring - won't break apart) attached to syringe or tubing into the middle of the port until rigid back of port is palpab
Decrease in weight - diuretics (watch K loss) - aldactone (k sparing but check renal fx) - inderal (do Not give to asthma patients or diabetic patients) - more exercise - no smoking - and decreased Na intake.

14. How is the arterial brachial index (ABI) calculated? Who should perform this? What is normal?
No radial artery punctures if negative
Positive Homan's sign (calf tenderness on dorsiflexion of the foot).
Iodine
It is calculated by checking the brachial BP and the ankle BP. The ankle systolic pressure is divided by the brachial systolic. The NA can perform. 0.97-1 is normal anything below indicates ischemia.

15. What is important to remember when removing a CVC from a patient?
Deep in the sternomastoid muscle - so look for pulsations in the soft tissue surrounding that area.
Have the patient use the val salva maneuver when the line is being removed (bear down/hold breath) to prevent air from entering where the line was and causing a PE.
Using both gloved hands - apply firm pressure just above the skin puncture site and over the hematoma to compress the area. Wait at least 15 mins before removing pressure and reassessing the site. Then notify the health care provider.
Maintain BED REST

16. What should be done immediately for someone with PE?
Fifth left intercostal space medial to the midclavicular line.
One large emboli (smaller=better)
Leg pain that is brought on by exercise and relieved by rest. It is characteristic of peripheral artery occlusion/ arterial insufficiency. It is dull or cramp like and consistently occurs in the same area of the leg and with same amount of distance.
Administer 100% O2 - left trendelenburg position - heparin administered - and oral warfarin started (give heparin and warfarin together for at least 5 days).

17. Where is the pulmonic valve landmark on the chest?
Second left intercostal space
Maintain BED REST
Vitamin K (aqua myphiton)
When they occur >6 per minute or occurring 2 or more in a row (bigeminy or trigeminy=on way out).

18. What is a nursing diagnosis for arterial occlusion? Tx
Decreased tissue perfusion. Tx: clot busting treatment must start within 6 hours.
Ventricular rate is regular at a rate of 40-60 bpm and there is no relationship of P waves to QRS complexes.
Explain procedure - stress importance of reporting symptoms. INSTRUCT The PATIENT NO TO EAT DRINK OR SMOKE AT LEAST 1 HOUR BEFORE The TEST. EVALUATE PATIENTS HISTORY FOR ANY CARDIAC CONDITIONS OR MEDICATIONS THAT MAY INTERFERE WITH The TEST!!! (No va
Using both gloved hands - apply firm pressure just above the skin puncture site and over the hematoma to compress the area. Wait at least 15 mins before removing pressure and reassessing the site. Then notify the health care provider.

19. What is the treatment for a pt. with ventricular tachycardia?
Patient who are unable to tolerate exercise stress testing.
All People Enjoy Time Magazine= Aortic - Pulmonic - ERB's point - Tricuspid - and Mitral/Apex. P(2) E (3) T (4) MA (5) (locations)
The right and left ventricular pressures - cardiac output - arterial venous O2 difference - and pulmonary artery pressure.
Awake and alert: IV lidocaine bolus and drip Unconscious - hypotensive - or S&S of angina/CHF: Direct current cardioversion and IV Lidocaine bolus and drip.

20. What is the treatment for someone with right sided HF? How do you know working?
Diuretic & Digoxin (dig increases force of contraction and increases perfusion). Know working if client is peeing (kidney perfusion) and more alert!
Stop What they are doing - sit down and rest - if prescribed nitroglycerin tablets place one under tongue - if it still remains take another tablet in 5 mins - and if still in pain take another after an additional 5 mins - if still pain after 3 table
Air answers (open junctions)
NO TED HOSE - NO SHEETS/BLANKETS - NO COMPRESSION DEVICES - (TEACH NO OPEN TOES SHOES). Lambs wool is okay!

21. What is the most common cause of arterial insufficiency?
Pulmonary edema
Chronic arteriosclerotic disease.
An inflammation of the pericardium. It may result in MI.
Stroke - renal or heart failure - paraplegia secondary to compromised blood flow - or death from aortic rupture.

22. When should bleeding precautions be implemented?
Feeling of fullness in head - tightness around shirt collar - or rings/jewelry that suddenly seem tight - swelling in face - hands - arms - and swollen/cyanotic lips - dyspnea - coughing - hoarseness - chest pain - hemotysis - visable collateral ches
Low pitched sounds such as S3 and S4 and the murmur of mitral stenosis. BEL(low)L
The symptoms improve when the patient is sitting in upright position that promotes drainage but worsen with the client is lying down.
When: using anticoagulants - liver disease - decrease in platelets (less than 150 -000) - hemophilia - using thrombolytic meds - DIC - CA - HIV - chemo - bone marrow problems - and ASA/NSAIDS.

23. How is the Allen's test done?
Ask patient to make a tight fist - using your index and middle fingers compress both the radial and ulnar arteries to obstruct blood flow to hand - ask pt to relax hand (hand and palm should appear blanched bc flow stopped) - release pressure on ulna
4th left intercostal space lower sternal border
Using both gloved hands - apply firm pressure just above the skin puncture site and over the hematoma to compress the area. Wait at least 15 mins before removing pressure and reassessing the site. Then notify the health care provider.
Elderly - hypothyroidism - renal dysfunction - dehydration - HYPOKALEMIA - hypomagnesemia - or hypercalcemia. Patients with abnormal potassium levels have a higher risk because hypokalemia makes the heart more sensitive to digoxin.

24. What is characteristic of atrial fibrillation?
No clearly defined or measurable P waves and an irregular - irregular ventricular response.
Used to look at vessels. A local anesthetic is injected and a catheter is inserted into a vessel in the area and advanced as necessary. A contrast medium is injected into the vessel than a series of xrays follow. Any flushing sensation/nausea/ or unu
Identify the highest point of pulsation and measure from this point to the sternal angle. A measurement of greater than 3 cm= an elevated venous pressure.
Rapid ventricular rate with no relationship to atrial activity and QRS complex is wide and bizarre.

25. What is the normal value for arterial pulse? Pulse amplitude? Edema? Reflex?
(1ST) BEGIN CARDIOPULMONARY RESUSCITATION (The PT. Is DYING) And NotIFY PHYSICIAN (2ND).
Arterial pulse: 60-90 - Amplitude: 4+=strong and bounding - Edema: 0=none - Reflex 2+
The internal jugular veins (external are less reliable).
Must be flushed 1x/month with heparin and between treatments.

26. What should you suspect for someone who post cardiac cath and percutaneous coronary intervention reporting feeling a pop in her left groin followed by a saturated dressing - swelling around site - palpable 2 inch fullness - and a bruit is present?
A hematoma= bleeding into the soft tissue surrounding the femoral artery access site.
A monitor with four dual electrodes that are applied to the patients neck and thorax.
Pulmonary edema
An inflammation of the pericardium. It may result in MI.

27. During an Allen's test don't compress one artery _____ the other.
(1st) Assess LOC - (2nd) if unconscious= begin CPR - and (3rd) Notify physician.
Second left intercostal space
Before
Iodine

28. What is characteristic of ventricular tachycardia?
Positive Homan's sign (calf tenderness on dorsiflexion of the foot).
Rapid ventricular rate with no relationship to atrial activity and QRS complex is wide and bizarre.
ST segment elevation (STEMI)
For the first month post op - do not lift more than 10 or 15 lbs. And avoid excessive pushing - pulling - or twisting.

29. What should you teach someone after they have had a pacemaker placed?

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30. What should you do to treat pulmonary edema?
Give furosemide (lasix) 40-60 mg IV - O2 administration - morphine sulfate 3-5 mg IV - have patient sit up with feet lowered (decreases venous return to the heart) - nitroglycerin given sublingual or IV - and rotating tourniquets (can reduce intratho
Close the open catheter lumen with the clamp - and place the pt on their left side in trendelenburg to move the air embolus away from the pulmonic valve. If you hear a churning sound in his chest (a classic sign of air embolus) and the patient starts
It is a test that examines the hearts response to being stressed by a pharmacologic agent. Persantine and adenosine vasodilate the coronary arteries and cause blood to shunt away from partially occluded coronary vessels. Then dobutamine stresses the
A fluid accumulation in the pericardial space that compromises cardiac function. It is considered a medical emergency and is a hemodynamic consequence of blood or excess fluid accumulation in the pericardial sac. Common causes are surgical or traumat

31. What does the device for impedance cardiography consist of?
Low pitched sounds such as S3 and S4 and the murmur of mitral stenosis. BEL(low)L
Hematuria (tea or coca cola colored) - nosebleeds - gingival bleeding (no medicated mouth wash - flossing - or lemon glycerin swabs) - and bruising (assess for abuse w/o caregiver).
Direct current shock (defibrillation) and IV anti - arrhythmic drugs (lidocaine - Procainamide - and Bretylium).
A monitor with four dual electrodes that are applied to the patients neck and thorax.

32. What should you teach someone with arterial insufficiency?

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33. What will the Transthoracic echocardiograph (TTE) show that will indicate cardiac tamponade?
Elderly - hypothyroidism - renal dysfunction - dehydration - HYPOKALEMIA - hypomagnesemia - or hypercalcemia. Patients with abnormal potassium levels have a higher risk because hypokalemia makes the heart more sensitive to digoxin.
NO NSAIDS or ASA.
Low pitched sounds such as S3 and S4 and the murmur of mitral stenosis. BEL(low)L
An enlarged space indicates fluid accumulation in the pericardial sac.

34. What should you teach your patient about a cardiac catheterization?
Lower HOB - place patient supine - assess LOC - open airway - assess breathing - get ambu bag - put on gloves - connect tubing from O2 source - adjust flow to 10 to 15 liters. First RESCUER: PLACE APEX of MASK OVER BRIDGE of NOSE And BASE BETWEEN LOW
International Normalized Ratio measures blood clotting time and compares it to normal values. 1.0=normal. Most people on anticoagulants are 2-3.
The physician injects a local anesthetic into the site - inserts a catheter - and threads it through the artery into the left side of the heart or through a vein into the right side of the heart to your lungs. Next - a dye is injected which may cause
High pitched sounds like S1 and S2 (pericardial friction rubs - aortic/mitral regurgitation murmurs). DIAPH(high)ragm

35. Where should you place your stethescope to find the ERB's Point?
(S1 - S2) Third left intercostal space
It is noninvasive. You must not eat - smoke - or drink alcohol for 3 hours before the test. WEAR COMFORTABLE SHOES And LOOSE LIGHTWEIGHT SHORTS OR SLACKS - YOU MAY GET AN INJECTION of THAllIUM - after your blood pressure and ECG are monitored for 10-
MRI is painless - you must remain still inside a small/noisy space. If you are claustrophobic you may need sedation. Remove all jewelry and other metal objects. If you have any shrapnel - a pacemaker - or any surgically implanted joints - pins - clip
Awake and alert: IV lidocaine bolus and drip Unconscious - hypotensive - or S&S of angina/CHF: Direct current cardioversion and IV Lidocaine bolus and drip.

36. What should you teach someone about iodine?
Second right intercostal space
Feeling warm (fire) or tin can taste is expected and will pass.
Lung disease
Right atrium - TRICUSPID VALVE (tissue) - right ventricle - PULMONIC VALVE (paper) - lungs - left atrium - MITRAL VALVE (My) - left ventricle - AORTIC VALVE (Assets). Tissue PAPER MY ASSETS!

37. What is superior vena cava syndrome?
Positive Homan's sign (calf tenderness on dorsiflexion of the foot).
When they occur >6 per minute or occurring 2 or more in a row (bigeminy or trigeminy=on way out).
A complication from a venous access device or port. It is a blockage of the superior vena cava preventing superior blood flow from reaching the heart.
Aortic valve - Pulmonic valve - right ventricle - tricuspid valve - and apex or mitral valve.

38. What condition can cause left sided heart failure?
Diuretic & Digoxin (dig increases force of contraction and increases perfusion). Know working if client is peeing (kidney perfusion) and more alert!
Vascular - artery disease causing fluid to back up into the lungs.
Chronic arteriosclerotic disease.
PT. Normal= 12 sec. If on anticoagulants it should be between 1 1/2 to 2 1/2 x the normal value. For PT= 18-30 sec.

39. What usually triggers angina pain?
It is a test that examines the hearts response to being stressed by a pharmacologic agent. Persantine and adenosine vasodilate the coronary arteries and cause blood to shunt away from partially occluded coronary vessels. Then dobutamine stresses the
It usually occurs when your heart is working harder (ex: exercising - eating large meal - or feeling stress. Also very hot or cold weather).
A clinician will perform echocardiogram guided pericardiocentesis with a needle or catheter to remove excess fluid in the pericardial sac.
Air embolism

40. What are common risk factors for an MI?
Pulmonary edema
Smoking - elevated cholesterol - diabetes - hypertension - old age - and family hx of coronary artery disease.
A central line placed that measures the right atrial pressure. Normal= 4-10 cm of H20.
BP is elevated or decreased depending on activity.

41. What should you know about your recovery period after having an implantable cardioverter defibrillator (ICD)?
Stroke - renal or heart failure - paraplegia secondary to compromised blood flow - or death from aortic rupture.
Leg pain that is brought on by exercise and relieved by rest. It is characteristic of peripheral artery occlusion/ arterial insufficiency. It is dull or cramp like and consistently occurs in the same area of the leg and with same amount of distance.
(S1 - S2) Third left intercostal space
For the first month post op - do not lift more than 10 or 15 lbs. And avoid excessive pushing - pulling - or twisting.

42. What will be the treatment for an acute episode of life threatening tamponade?
Gently insert the oropharyngeal airway by turning it upside down (into U shape) and slide it into the mouth. As continue to insert rotate it so the ends of the U turn downward into an arch shape after it transverses the oral cavity and approaches the
A clinician will perform echocardiogram guided pericardiocentesis with a needle or catheter to remove excess fluid in the pericardial sac.
Lower left sternal border
A central line placed that measures the right atrial pressure. Normal= 4-10 cm of H20.

43. A femoral artery compression device ______be assigned to an NA?
Rescuer arrives with AED - turn AED on - select proper pads and apply - clear victim to analyze - clear victim to shock/press shock - resume chest compressions after 1 shock - delivers cycle of compressions at correct rate - pause to allow other resc
Direct current shock (defibrillation) and IV anti - arrhythmic drugs (lidocaine - Procainamide - and Bretylium).
Cannot
ST segment elevation (STEMI)

44. What is a good diagnosis for someone with right sided HF?
This noninvasive test takes 24 hours and causes no discomfort. Electrodes are applied to your body - you need to log your activities for a 24 hour period (walking - sleeping - urinating - physical symptoms - and medications). Don't tamper with the mo
Activity intolerance
International Normalized Ratio measures blood clotting time and compares it to normal values. 1.0=normal. Most people on anticoagulants are 2-3.
No radial artery punctures if negative

45. What is Deep Vein Thrombosis (DVT)?
Close the open catheter lumen with the clamp - and place the pt on their left side in trendelenburg to move the air embolus away from the pulmonic valve. If you hear a churning sound in his chest (a classic sign of air embolus) and the patient starts
A disease in which thrombi trap blood in the deep veins of the pelvis and legs.
Demand: Works PRN (when HR goes below predetermined rate) or Fixed: beats constantly at predetermined rate so no matter what heart does still beats at same rate.
Second right intercostal space

46. What are the indications for a chemical stress test (persantine stress test)?
Patient who are unable to tolerate exercise stress testing.
Nitrates - Beta blockers - and Calcium channel blockers
No radial artery punctures if negative
Deep in the sternomastoid muscle - so look for pulsations in the soft tissue surrounding that area.

47. What would make someone more at risk for digoxin toxicity?
Lower HOB - place patient supine - assess LOC - open airway - assess breathing - get ambu bag - put on gloves - connect tubing from O2 source - adjust flow to 10 to 15 liters. First RESCUER: PLACE APEX of MASK OVER BRIDGE of NOSE And BASE BETWEEN LOW
No clearly defined or measurable P waves and an irregular - irregular ventricular response.
Premature beats that are not preceded by a P- wave - QRS is wide and bizarre - and the T wave of the premature beat is generally large and in the opposite direction of the QRS.
Elderly - hypothyroidism - renal dysfunction - dehydration - HYPOKALEMIA - hypomagnesemia - or hypercalcemia. Patients with abnormal potassium levels have a higher risk because hypokalemia makes the heart more sensitive to digoxin.

48. What are the five areas for listening to the heart?

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49. What SE should you look for with calcium channel blocker use?
The symptoms improve when the patient is sitting in upright position that promotes drainage but worsen with the client is lying down.
Constipation or MAY CAUSE ANKLES TO SWELL (call healthcare provider).
IV LIDOCAINE BOLUS (50-100 mg) followed by an IV lidocaine drip (suppresses ventricular activity).
Anxiousness - restlessness - tachycardia - tachypneic - 90% SP02 - dyspnea - substernal pain - coughing - hemoptysis - and fever.

50. What are the S&S of pulmonary embolism?
0.5-2.0 ng/ml
Stand behind the victim - wrap arms around waist (IF PREGNANT WRAP ABOVE The BABy) - make a fist with one had and place thumb against abdomen midline - grasp fist with other hand - press into victims abdomen with quick upward thrusts.
Anxiousness - restlessness - tachycardia - tachypneic - 90% SP02 - dyspnea - substernal pain - coughing - hemoptysis - and fever.
They may feel a slight stinging under there tongue when they are dissolving - and they should get a HA (if no HA may not be good bc the pills only last for 6 months). Keep with you at all times.