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.
Nursing Test Bank
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Related Questions
Correct Answer is A
Explanation
Rationale:
A. An echocardiogram is a diagnostic test that uses sound waves to create images of the heart's chambers, valves, and surrounding structures, and assesses their function.
B. Fasting is not typically required for an echocardiogram.
C. Discomfort is not typically associated with an echocardiogram.
D. An echocardiogram does not typically assess the extent of blockages in the arteries.
Correct Answer is D
Explanation
Rationale:
A. This is not correct since a sinus tachycardia show have a sinus P wave unlike in the strip.
B. This is incorrect since a junctional rhythm should have a regular ventricular rhythm unlike in the above strip which is irregular.
C. A first degree heart block should have a PR interval greater than 0.20 without a disruption in the atrial to ventricular conduction.
D. This is correct since the rhythm is irregular and the P waves are absent.
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