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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. An echocardiogram does not assess coronary artery blockages; a coronary angiogram or cardiac catheterization is used for that.
B. Fasting is not required for a standard transthoracic echocardiogram. However, fasting may be needed for a transesophageal echocardiogram (TEE).
C. An echocardiogram is a non-invasive ultrasound test that evaluates heart structure, valve function, and cardiac muscle performance.
D. There is no discomfort during a transthoracic echocardiogram, as it is performed externally using a probe on the chest.

A. Count how many QRS complexes occur in a 6-second strip B. Measure the T waves C. Read the monitor or electrocardiogram interpretation D. Look for P waves on the strip

Correct Answer is A

Explanation

A. Counting the number of QRS complexes in a 6-second strip and multiplying by 10 provides an estimate of the heart rate per minute.
B. Measuring T waves is used to assess repolarization abnormalities, not to determine heart rate.
C. While the monitor provides a heart rate reading, manual calculation is essential for verifying accuracy.
D. P waves indicate atrial activity but are not used to calculate the overall heart rate.

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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?

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Naxlex Comprehensive Predictor Exams

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