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. While potassium is typically diluted in IV fluids, the concentration and infusion rate must be clarified before administration. A standard dilution is 10 mEq in 100 mL or 40 mEq in 1L, but this must be verified.
B. Calling the physician for clarification is the safest step. IV potassium should never be given undiluted or as an IV push due to the risk of fatal cardiac arrhythmias.
C. IV push potassium is never appropriate as it can cause cardiac arrest.
D. Administering the undiluted 20 mEq/mL solution is dangerous and requires proper dilution before administration.
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