Question

A nurse is checking the ECG Rhythm strip for a client who has a temporary pacemaker. The nurse notes a spike or a pacemaker artifact followed by a QRS complex. Which of the following actions should the nurse take?

A) Administer an antiarrhythmic medication.
B) Increase the pacemaker rate.
C) Document the findings as normal.
D) Assess the client for signs of pacemaker malfunction.

Answer 1

If a nurse notes a spike or pacemaker artifact followed by a QRS complex on an ECG rhythm strip of a client with a temporary pacemaker, the appropriate action would be to document the findings as normal.

Step-by-step explanation:

When checking an ECG rhythm strip for a client with a temporary pacemaker, if the nurse notes a spike or pacemaker artifact followed by a QRS complex, it indicates that the pacemaker is functioning correctly.

Therefore, the appropriate action for the nurse to take in this case would be to document the findings as normal. There is no need for any intervention or medication unless there are other signs of pacemaker malfunction.

Assessing the client for signs of pacemaker malfunction would be an important step to take if there are any concerns or additional symptoms present that suggest a problem with the pacemaker.