Difficulty: Medium
Average Score: 90%
Simulated
The nurse is caring for a client who has had a temporary transvenous pacemaker inserted. The cardiac monitor shows pacemaker spikes occurring at various points in the client's own beats such as on the T wave. What action is the nurse's priority?
Correct answer
D
Rationale
Pacemaker spikes on the T wave indicate a sensing issue, requiring immediate notification of the provider.