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 D

Explanation

A. Complete heart block (third-degree AV block) is characterized by a complete dissociation between atrial and ventricular activity, with P waves and QRS complexes occurring independently of each other.
B. Sinus tachycardia presents with a regular rhythm, a heart rate above 100 beats per minute, and distinct P waves preceding each QRS complex.
C. Idioventricular rhythm occurs when the heart's primary pacemakers fail, leading to a slow ventricular rate (usually 20-40 bpm) with wide QRS complexes and no preceding P waves.
D. Ventricular tachycardia (VT) is a life-threatening arrhythmia characterized by a rapid ventricular rate (typically >100 bpm), wide QRS complexes, and an absence of P waves. VT can be sustained or non-sustained and may require immediate intervention if the patient is unstable.

A. Amiodarone administration B. Defibrillation C. Epinephrine administration D. Synchronized Cardioversion

Correct Answer is B

Explanation

A. Amiodarone is an antiarrhythmic medication used after defibrillation and CPR in persistent ventricular fibrillation (VF) or ventricular tachycardia (VT). However, it is not the first priority.
B. Defibrillation is the immediate priority in a pulseless client with ventricular fibrillation. Early defibrillation increases the chances of survival. The shock should be delivered as soon as possible.
C. Epinephrine is given after the first defibrillation and CPR cycle, not before.
D. Synchronized cardioversion is inappropriate because it is used for unstable tachyarrhythmias with a pulse, not pulseless VF.

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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

Identify the following Cardiac Rhythm:

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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