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 A
Explanation
A. Dyspnea is the priority finding as it may indicate heart failure or pulmonary embolism, both of which are life-threatening complications of infective endocarditis.
B. Anorexia is a common symptom but is not an immediate threat to the client's condition.
C. Malaise is a general symptom of infection but does not require urgent intervention.
D. Fever is a hallmark sign of infection but is not as critical as assessing for complications such as heart failure or embolic events.
Correct Answer is B
Explanation
A. A weight gain of 1 lb in a week may not indicate fluid overload, but a more rapid increase is concerning.
B. A weight gain of 2 lbs in 24 hours or 5 lbs in a week suggests worsening heart failure due to fluid retention, requiring immediate provider notification.
C. Daily weights should be taken at the same time each day, preferably in the morning, after urination and before eating, for accurate monitoring.
D. Skipping a diuretic dose can lead to fluid retention and worsening symptoms, so adherence to the medication regimen is crucial.
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