The nurse is assessing a new admission and hears a murmur at the second left intercostal space along the left sternal border. The nurse anticipates the client has a murmur of which valve?

A. Complete the remainder of the assessment: While ongoing assessment is important, the rhythm strip shows atrial flutter, a potentially unstable arrhythmia, and the client is experiencing symptoms (nausea after breakfast) which could suggest compromised cardiac output. Completing the remainder assessment delays the necessary intervention.

B. Obtain an order for adenosine IV: Adenosine is typically used for stable supraventricular tachycardia (SVT), not for atrial flutter, as it may not terminate the rhythm. It may slow conduction enough to better visualize flutter waves, but initiating it without a provider's order or further evaluation is inappropriate.

C. Notify the physician of the symptoms: The client’s rhythm strip shows atrial flutter with a rapid ventricular response and the patient is experiencing nausea, which could indicate decreased perfusion or early decompensation. Immediately notifying the provider is the safest and most appropriate action for further evaluation and treatment planning.

D. Administer the prescribed ACE inhibitor: ACE inhibitors are used for blood pressure control or heart failure management, not for acute rhythm disturbances. Administering it would not address the current rhythm or symptoms and could worsen hypotension if cardiac output is compromised.

A. Increase the pacemaker sensitivity: Adjusting pacemaker sensitivity is a technical function typically managed by a cardiologist or device technician. There is no indication from the information provided that the pacemaker is under- or over-sensing, so no adjustment is warranted.

B. Document that the pacemaker is regular: While the pacemaker may be functioning regularly, this statement is vague and does not accurately describe the observed pacing activity. The key observation is the spike occurring before the P wave, which requires more specific documentation.

C. Set the pacemaker to the asynchronous mode: Asynchronous pacing means the pacemaker fires at a set rate regardless of the patient's intrinsic rhythm and is generally reserved for specific situations such as during surgery or when interference with sensing is suspected. There is no evidence of pacemaker malfunction or need to override sensing in this scenario.

D. Document that the atria are being paced: A pacemaker spike immediately before the P wave indicates atrial pacing. This means the pacemaker is stimulating the atria, leading to atrial depolarization. This is the appropriate interpretation and should be documented clearly.