A client is unconscious on arrival to the emergency department. The nurse in the emergency department identifies that the client has a permanent pacemaker due to which characteristic?

Quality of the pulse

"Spike" on the rhythm strip

Scar on the chest

Vibration under the skin

Answer and Explanation

The Correct Answer is B

A. Quality of the pulse: Pulse quality may indicate the presence of a rhythm, but it cannot confirm the presence of a pacemaker. A strong or weak pulse can occur in many conditions and is not a reliable pacemaker indicator.
B. "Spike" on the rhythm strip: Pacemakers produce a visible electrical “spike” on an ECG or rhythm strip, which precedes the QRS complex (or P wave in atrial pacing)or both (dual-chamber pacing). This spike confirms that the electrical impulse is generated by a pacemaker.
C. Scar on the chest: A scar may suggest prior pacemaker placement, but it is not definitive. Scars could be from other procedures or surgeries and do not confirm current pacemaker function.
D. Vibration under the skin: Pacemakers do not vibrate and typically cannot be felt moving under the skin. This is not a feature of the device and would not help identify its presence.

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Correct Answer is A

Explanation

A. Avoid crossing the legs: Crossing the legs can impede venous return by compressing the veins in the leg therefore increasing the risk of clot formation in the lower extremities. Teaching clients to keep legs uncrossed helps maintain proper circulation and reduces venous stasis postoperatively.
B. Massage the calves and thigh: Massaging the legs can dislodge an existing thrombus, leading to a potential pulmonary embolism. This practice is contraindicated in clients at risk for deep vein thrombosis (DVT).
C. Prop pillows under knees: Placing pillows under the knees promotes venous stasis by compressing the popliteal vein. This can increase the risk of thrombophlebitis and should be avoided in post-op care.
D. Encourage ambulation twice daily: Although ambulation is beneficial, twice daily may not be frequent enough to adequately promote circulation. More regular movement and leg exercises are typically recommended to prevent clot formation.

A. A drop in diastolic blood pressure (25 mmHg) upon rising B. A pulsating headache C. A blood pressure elevation upon activity D. A drop in systolic blood pressure (15 mm Hg) upon rising

Correct Answer is A

Explanation

A. A drop in diastolic blood pressure (25 mmHg) upon rising: Orthostatic (postural) hypotension is diagnosed by a drop of ≥20 mmHg systolic or ≥10 mmHg diastolic within 3 minutes of standing. A 25 mmHg drop in diastolic pressure is a significant change and meets criteria for this condition.
B. A pulsating headache: While a headache may accompany blood pressure fluctuations, it is not a defining symptom of postural hypotension. It lacks the diagnostic specificity needed to confirm this condition.
C. A blood pressure elevation upon activity: An increase in blood pressure during activity is expected and not diagnostic of postural hypotension. In fact, postural hypotension involves a blood pressure drop upon standing, not a rise.
D. A drop in systolic blood pressure (15 mm Hg) upon rising: A 15 mmHg systolic drop does not meet the threshold for orthostatic hypotension. For diagnosis, the systolic pressure must drop by at least 20 mmHg within 3 minutes of standing.

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A client is unconscious on arrival to the emergency department. The nurse in the emergency department identifies that the client has a permanent pacemaker due to which characteristic?

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