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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.

Answer and Explanation

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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Correct Answer is D

Explanation

Rationale:

A. Synchronized cardioversion is not appropriate for pulseless ventricular tachycardia.

B. A repeat ECG is not necessary for pulseless ventricular tachycardia.

C. Assessment of blood pressure is not the priority in pulseless ventricular tachycardia.

D. Immediate defibrillation is the priority in pulseless ventricular tachycardia to restore a perfusing rhythm.

A. Reduce Blood pressure until patient is asymptomatic B. Reduce the blood pressure to normal over a period of hours. C. Reduction of blood pressure to normal over a period of days D. Reduction of blood pressure by 50% in the first hour.

Correct Answer is D

Explanation

Rationale:

A. Reducing blood pressure until the patient is asymptomatic is not specific and may not be achievable or safe.

B. Reducing the blood pressure to normal over a period of hours may be too slow for a hypertensive emergency.

C. Reducing blood pressure to normal over a period of days is too slow for a hypertensive emergency.

D. The goal in a hypertensive emergency is to reduce blood pressure by 25% to 30% within the first hour, with the ultimate goal of a reduction of 50% in the first hour.

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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?

Nursing Test Bank

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