A nurse is caring for a client in the emergency department (ED). Afib
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
- Atrial fibrillation is characterized by an irregular, often rapid heart rate that can lead to poor blood flow. The client's symptoms of a "fluttering" and "racing" heartbeat, dizziness, and shortness of breath, along with the irregular cardiac rhythm and unclear P waves, are indicative of atrial fibrillation.
- Obtaining a 12 lead ECG is essential to confirm the diagnosis and assess the extent of the arrhythmia.
- Administering an anticoagulant is crucial to prevent thromboembolic events, such as stroke, which are common complications of atrial fibrillation.
- Monitoring for manifestations of stroke is important because atrial fibrillation increases the risk of stroke.
- PT/INR should be monitored to ensure the effectiveness and safety of anticoagulant therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Ascites is the accumulation of fluid in the peritoneal cavity, often due to liver disease such as cirrhosis. It does not directly cause the formation of biliary sludge, which is related to bile composition and flow.
B. Biliary colic refers to pain caused by the gallbladder's inability to expel bile, often due to a gallstone blocking the bile duct. While biliary colic may be associated with gallstones, it is not the primary cause of biliary sludge.
C. Bile stasis is the primary cause of biliary sludge. It occurs when bile remains in the gallbladder for an extended period, leading to the formation of thickened bile and sludge. Factors such as fasting, pregnancy, or liver disease can contribute to bile stasis.
D. Hepatitis is an inflammation of the liver, which may affect bile production but does not directly cause biliary sludge. Hepatitis can lead to other complications such as jaundice but is not the main cause of biliary sludge formation.
Correct Answer is C
Explanation
A. Troponin is not an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. It is a protein specifically related to heart muscle injury. Therefore, this explanation is inaccurate.
B. Troponin is not a lipid, and it does not reflect the risk for coronary artery disease. It is a cardiac-specific protein released into the bloodstream when heart muscle cells are damaged, particularly during a myocardial infarction.
C. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. It is a highly sensitive and specific marker for myocardial injury, making it a critical test for diagnosing a myocardial infarction.
D. Troponin is not involved in oxygen transport. Hemoglobin is the protein responsible for oxygen transport throughout the body, not troponin.
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