The nurse in the cardiac observation unit is caring for a 56-year-old female client.
1000:Client reports new intermittent palpitations. The electrocardiogram shows frequent early ventricular beats with wide, unusual complexes between otherwise regular sinus beats. Blood pressure is stable and the client is alert. The primary health care provider (PHCP) has not yet been told about the new frequency. Intake of caffeine and other stimulants has not been assessed. Blood samples for potassium and magnesium are collected; results are pending.
For each potential nursing action, click to specify whether the action is indicated or not indicated for the care of the client.
| Potential Nursing Actions | Indicated | Not Indicated |
|---|---|---|
| Assess for chest discomfort and dizziness. | ||
| Ask about caffeine and other stimulant use. | ||
| Notify the PHCP of the new frequent ectopy. | ||
| Review the potassium and magnesium results when available. | ||
| Reassure the client that further assessment is unnecessary. |
Note: Each row must have 1 response option selected.