Medical Surgical Myocardial Infarction #10

Question

The nurse is caring for a client with a 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?

Answers

  1. Immediately go to the client's hospital room and assess telemetry lead placement
    • Rationale:

      This answer is correct because the nurse’s priority action when a telemetry monitor is indicating abnormal and odd findings is to first check the client, then the telemetry lead placement. Telemetry monitoring and troubleshooting is the nurse’s responsibility.

  2. Immediately call a Code and bring the crash cart to the client's room
    • Rationale:

      This answer is not correct because when monitoring a client’s telemetry monitor, the nurse’s priority action when a monitor is indicating abnormal and odd findings is to first check the client, then the telemetry lead placement. Calling the health care provider for pulseless electrical activity is not appropriate until the client is checked and proper lead placement is confirmed.

  3. Immediately call the health care provider for pulseless electrical activity
    • Rationale:

      This answer is not correct because when monitoring a client’s telemetry monitor, the nurse’s priority action when a monitor is indicating abnormal and odd findings is to first check the client, then the telemetry lead placement. Calling a Code and bringing the crash cart to the client’s room is not appropriate until the client is checked and proper lead placement is confirmed.

  4. Immediately record the telemetry findings at the main telemetry station
    • Rationale:

      This answer is not correct because recording the telemetry findings at the main telemetry station is not appropriate until the client is checked and proper lead placement is confirmed.

Overview

The nurse’s priority action when a telemetry monitor is indicating abnormal and odd findings is to first check the client, then the telemetry lead placement. Telemetry monitoring and troubleshooting is the nurse’s responsibility.

Explanation

Learning Outcomes

Telemetry monitoring and troubleshooting is the nurse’s responsibility. If anything abnormal or unusual occurs, the nurse should first check the client then ensure that telemetry leads are placed appropriately. While in the room, the nurse may assess the condition of the client 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 client. Call a code if unstable. If stable and asymptomatic, and arrhythmia has been verified, call the health provider.

Test Taking Tip

Remember to always treat the client, not the monitor.

Video Rationale