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.
Answer: B
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Which of the following task(s) may be delegated to a certified nursing assistant (CNA)? Select all that apply
a. Measuring and recording intake and output b. Performing a bedside dipstick urine test c. Applying a condom catheter to a male patient d. Assessing a patient's ability to collect a urine specimen e. Determining which type of catheter to insert
The breastfeeding mother is concerned about her decreased production of milk. The nurse knows further teaching is needed based on which statement?
1. "I am drinking a minimum of 8–10 glasses of liquid a day." 2. "I have started cutting back on my protein intake." 3. "At least three times a day, I am drinking a glass of milk." 4. "I try to take a nap in the morning and afternoon when the baby is sleeping."
A nurse knows that the mother understands the discharge instructions for an 8 month old that had a cardiac catheterization for an ASD when the mother states:
1. "We will need to schedule weekly visits to make sure the heart is functioning properly.". 2. "The surgical site will require us to keep our child in isolation at home.". 3. "We will need to monitor the insertion site for drainage and temperature changes.". 4. "My child will not have any more issues with arrhythmias.".
The nurse is teaching a patient about the purpose of his telemetry. Which statement indicates that the nurse's teaching has been successful?
a. "I will need to stay in bed when the mon-itor is reading my heart waves." b. "This test will help determine if I have a blockage in my arteries." c. "If there is a problem with my heart valves, it will show up with telemetry." d. "The nurses will be able to monitor my heart rate and rhythm."