Cardiac Question #39
The nurse is caring for a client with telemetry heart monitor, and notices flat electrocardiographic complexes and occasional sinus rhythm. The monitor alarms sound when cardiac complexes become absent, and then alarms cease when sinus rhythm occurs. Which is the priority action by the nurse?
- Immediately go to the client’s hospital room and assess telemetry lead placement
- Immediately call a Code and bring the crash cart to the client’s room
- Immediately call the health care provider for pulseless electrical activity
- Immediately record the telemetry findings at the main telemetry station
The nurse should ensure that telemetry leads are placed appropriately, and while in the room, the nurse may assess condition of the patient such as level of consciousness, complaints of pain or palpitations, or other findings. Telemetry artifacts may appear like arrhythmias or even asystole. First confirm that the arrhythmia is real and check on the patient. Call a code if unstable. If stable and asymptomatic, and arrhythmia has been verified, call the health provider. Know policies and procedures.
Test Taking Tip