A nurse is admitting a client who has a history of atrial fibrillation. Which of the following conditions should the nurse recognize atrial fibrillation places the client at risk for?

Hemothorax

Cardiac tamponade

Pulmonary emboli

Widened pulse pressure

Answer and Explanation

The Correct Answer is C

Rationale:
A. Hemothorax: Hemothorax is accumulation of blood in the pleural space, typically caused by trauma, surgery, or ruptured vessels. Atrial fibrillation does not directly increase the risk of hemothorax.

B. Cardiac tamponade: Cardiac tamponade occurs when fluid accumulates in the pericardial sac, impairing cardiac output. This condition is usually associated with trauma, pericarditis, or post-surgical complications, not atrial fibrillation.

C. Pulmonary emboli: Atrial fibrillation can lead to stasis of blood in the atria, especially the left atrial appendage, increasing the risk of thrombus formation. If a clot dislodges and travels to the lungs, it can cause a pulmonary embolism, making this a serious complication to monitor for.

D. Widened pulse pressure: Widened pulse pressure reflects the difference between systolic and diastolic blood pressure and is associated with conditions like aortic regurgitation. It is not a direct consequence of atrial fibrillation and is not considered a primary risk in these clients.

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Correct Answer is C

Explanation

Rationale:
A. "This medication can increase your risk for osteoporosis.": Long-term warfarin use may affect bone density slightly, but this is not the primary teaching point for safety and daily management. It is less immediately relevant than bleeding risk.

B. "This medication can cause hearing loss.": Warfarin is not associated with ototoxicity or hearing loss; this statement does not reflect a known adverse effect of the medication.

C. "Avoid drinking cranberry juice while taking this medication.": Cranberry products can interact with warfarin and increase the risk of bleeding by potentiating its anticoagulant effect. Clients should be advised to avoid or limit cranberry intake to maintain safe INR levels.

D. "Increase your intake of foods high in vitamin K while taking this medication.": Consuming consistent amounts of vitamin K is important, but the client does not need to increase intake. Sudden increases can counteract warfarin’s effect; the emphasis is on maintaining a stable vitamin K intake.

A. A client who has dementia and is incontinent of urine B. A client who has had a recent myocardial infarction C. A client who has a T-tube following an open cholecystectomy D. A client who is 2 days postoperative following orthopedic surgery

Correct Answer is A

Explanation

Rationale:
A. A client who has dementia and is incontinent of urine: Cognitive impairment and incontinence significantly increase the risk for pressure injuries. Dementia may limit mobility and the ability to communicate discomfort, while moisture from incontinence leads to skin breakdown, making this client the highest risk.

B. A client who has had a recent myocardial infarction: While immobility after a myocardial infarction can contribute to pressure injury risk, this client typically has fewer direct risk factors compared with incontinence and cognitive impairment.

C. A client who has a T-tube following an open cholecystectomy: Postoperative clients with a T-tube are at moderate risk due to temporary immobility, but they usually maintain mobility and can reposition, reducing overall risk compared with incontinent or cognitively impaired clients.

D. A client who is 2 days postoperative following orthopedic surgery: Early postoperative orthopedic clients are at risk due to immobility, but with appropriate repositioning, pressure-relieving devices, and monitoring, their risk is generally lower than a client with incontinence and dementia.

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A nurse is admitting a client who has a history of atrial fibrillation. Which of the following conditions should the nurse recognize atrial fibrillation places the client at risk for?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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