Which is the priority nursing intervention for a patient with a junctional escape rhythm?
1. Assess the patient for symptoms associated with this rhythm.
2. Contact the physician immediately for emergency orders.
3. Eliminate caffeine from the diet.
4. Prepare for a pacemaker insertion.
1
Rationale 1: Junctional escape rhythms may be monitored if the patient is not symptomatic. It is most important to assess the patient to see how he or she is affected by the rhythm.
Rationale 2: After another intervention is performed, calling the physician to report the rhythm may be appropriate.
Rationale 3: Eliminating caffeine is not an appropriate action for this patient. There is no indication of symptoms relating to the rhythm.
Rationale 4: Preparing for a pacemaker insertion is not an appropriate action for this patient. There is no indication of symptoms relating to the rhythm.
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