A nurse is caring for a client diagnosed with atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?
The client experiences sudden weakness of one arm and leg
The client's ECG tracing shows irregular heart rate without P waves.
The client's urine output is cloudy and odorous.
The client has an aPTT of 80 seconds.
The Correct Answer is A
Rationale:
A. Sudden weakness of one arm and leg may indicate a stroke, which is a potential complication of atrial fibrillation.
B. An irregular heart rate without P waves is characteristic of atrial fibrillation and is expected.
C. Cloudy and odorous urine may indicate a urinary tract infection but is not the priority in this case.
D. An aPTT of 80 seconds is within the therapeutic range for heparin therapy.
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Related Questions
Correct Answer is C
Explanation
Rationale:
A. Diminished breath sounds are not typically associated with a pericardial effusion.
B. Increased blood pressure is not typically associated with a pericardial effusion but it can instead result in hypotension due to decreased cardiac output due to compression of the heart by the accumulated fluid.
C. The heart sounds may become faint or distant due to fluid accumulation around the heart.
D. A new systolic murmur may indicate a pericardial effusion and should be further evaluated.
Correct Answer is ["C","D"]
Explanation
Rationale:
A. A BMI of 20 is not typically considered a risk factor for deep vein thrombosis.
B. High calcium intake is not typically considered a risk factor for deep vein thrombosis.
C. Oral contraceptive use is a risk factor for deep vein thrombosis due to the estrogen content.
D. Immobility is a risk factor for deep vein thrombosis due to decreased venous return.
E. Hypertension is not typically considered a risk factor for deep vein thrombosis.
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