A Nurse Is Providing Care to a Client with a Temporary

question 10

Multiple Choice

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.

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