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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 ["A","B","C","E","F"]

Explanation

Rationale:

A. Unable to lie flat due to orthopnea is a sign of worsening heart failure.

B. Feeling fatigued is a general symptom of heart failure but can worsen as heart failure progresses.

C. Distended neck veins indicate increased central venous pressure, which is a sign of worsening right-sided heart failure.

D. Increased appetite is not typically associated with worsening heart failure.

E. Weight gain of 2 pounds in 24 hours indicates fluid retention and worsening heart failure.

F. Worsening lower extremity edema is a sign of worsening heart failure.

A. Murmur B. S3 and S4 C. Click D. Friction rub

Correct Answer is A

Explanation

Rationale:

A. Mitral valve regurgitation typically presents with a murmur, which is a characteristic sound associated with the backflow of blood into the left atrium during systole.

B. S3 and S4 are not typical heart sounds and do not relate to mitral valve regurgitation.

C. A click is typically associated with mitral valve prolapse, not mitral valve regurgitation.

D. A friction rub is typically associated with pericarditis, not mitral valve regurgitation.

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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

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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