A nurse is caring for a client diagnosed with atrial fibrillation who is receiving continuous IV heparin. Which of the following findings is the nurse's priority?
The client has an INR of 2.
The client has an aPTT of 80 seconds.
The client experiences sudden weakness of one arm and leg.
The client's ECG tracing shows irregular heart rate without P waves.
The Correct Answer is C
A. An INR of 2 is within the therapeutic range for anticoagulation but is more relevant for warfarin therapy rather than heparin.
B. An aPTT of 80 seconds is slightly elevated but not immediately life-threatening. The therapeutic range for heparin is typically 1.5 to 2.5 times the normal value (approximately 60-80 seconds).
C. Sudden weakness of one arm and leg suggests a possible embolic stroke, which is a serious complication of atrial fibrillation. This requires immediate assessment and intervention.
D. An irregular heart rate without P waves is characteristic of atrial fibrillation but is not the most urgent concern compared to potential stroke symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
- Determine the heparin concentration:
- You have 25,000 units of heparin in 250 mL of normal saline.
- Concentration = 25,000 units / 250 mL = 100 units/mL
- Calculate the mL/hr rate:
- The order is for 1,000 units/hour.
- Drip rate (mL/hr) = 1,000 units/hour / 100 units/mL = 10 mL/hour
Answer = 10mL/hr
Correct Answer is A
Explanation
A. Digoxin is a positive inotropic agent, meaning it increases the force of cardiac contractions. This helps improve cardiac output in patients with heart failure.
B. Digoxin does not decrease the force of contractions; instead, it strengthens them, making it beneficial for heart failure treatment.
C. Digoxin is commonly used in heart failure management, particularly in cases of systolic dysfunction or atrial fibrillation.
D. Digoxin decreases heart rate by slowing conduction through the atrioventricular (AV) node, making it useful in atrial fibrillation, but its primary benefit in heart failure is increasing contractility.
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