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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 C

Explanation

Rationale:

A. This is wrong because the ECG leads show ST segment elevation.

B. Stable angina may present with ST segment depression in an ECG unlike in the strip shown above which depicts an ST segment elevation.

C. This is correct because of the ST segment elevation.

D. Unstable angina may have hyperacute T wave, flattening of the T waves, inverted T waves or an ST depression unlike in the above ECG strip.

A. Sinus Tachycardia B. Ventricular Tachycardia C. Complete Heart Block D. Idioventricular Rhythm

Correct Answer is B

Explanation

A. A sinus tachycardia is characterized by a sinus P wave at a rate of more than 100 per minute followed by a narrow QRS complex unlike in the strip depicted above.

B. The above ECG strip shows a ventricular tachycardia based on the wide QRS with a rate more than 120 bpm, AV dissociation and the fusion beats.

C. A complete heart block is characterized by QRS complexes being conducted at their own rates and totally independent of the P wave.

D. An idioventricular rhythm is characterized by a slow regular ventricular rhythm with a rate less than 50 bpm unlike in the above strip. It also has a prolonged QRS interval with no P wave.

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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?

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