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A nurse is providing care to a client with a temporary pacemaker. The nurse observes a spike on the ...

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A nurse is providing care to a client with a temporary pacemaker. The nurse observes a spike on the ...

A nurse is providing care to a client with a temporary pacemaker. The nurse observes a spike on the ECG. What should the nurse do first?

▸ Notify the healthcare provider that the client is having an arrhythmia.

▸ Document the client's rhythm, pacing spikes, and post strip in the client's chart.

▸ Complete the pain assessment because this is an irregular finding and causes pain.

▸ Delegate this client to the UAP until the temporary pacemaker is not needed.

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Clinical Nursing Skills: A Concept-Based Approach

Edition: 3^rd

Author: Callahan

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