Loss of capture has occurred in a patient with a temporary pacemaker. Which nursing actions are required? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Prepare for cardiac resynchronization therapy (CRT).
2. Assess the patient to determine response to the pacemaker loss of capture.
3. Document the event by printing the ECG strip and placing it on the patient's record.
4. Ask the patient to ambulate to increase cardiac output.
5. Administer nitroglycerin sublingual one dose stat according to physician prescription.
1,2,3
Rationale 1: CRT is a type of atrial-synchronized biventricular pacemaker. There is no indication that this therapy would be appropriate.
Rationale 2: The nurse should assess the patient to determine the response to the loss of capture.
Rationale 3: The nurse should document the event by printing an ECG strip and placing it on the patient's record.
Rationale 4: Having the patient ambulate would not be indicated for pacemaker malfunction.
Rationale 5: Administering nitroglycerin would not be indicated for pacemaker malfunction. Nitroglycerin is administered for chest pain.
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