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?
A)Notify the healthcare provider that the client is having an arrhythmia.
B)Document the client's rhythm,pacing spikes,and post strip in the client's chart.
C)Complete the pain assessment because this is an irregular finding and causes pain.
D)Delegate this client to the UAP until the temporary pacemaker is not needed.

Question

Quizplus · Accepted Answer

The observation of a spike on the ECG in a client with a temporary pacemaker indicates that the pacemaker is delivering an electrical impulse. This is an expected finding, not an arrhythmia or an indication of pain. The first action the nurse should take is to document the client's rhythm, pacing spikes, and post a strip in the client's chart. This documentation is crucial for ongoing assessment and management of the client's condition. Notifying the healthcare provider, assessing for pain, or delegating care to an unlicensed assistive personnel (UAP) are not appropriate first steps in response to this expected finding.

A Nurse Is Providing Care to a Client with a Temporary