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choco1433 choco1433
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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.
Textbook 
Clinical Nursing Skills: A Concept-Based Approach

Clinical Nursing Skills: A Concept-Based Approach


Edition: 3rd
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PWT82PWT82
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Document the client's rhythm, pacing spikes, and post strip in the client's chart.

This nurse needs to document the findings because this is a normal response to a client who has a temporary pacemaker.
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