A nurse is educating a Type 1 diabetic client with new-onset atrial fibrillation about the risks associated with the condition.
Which complications should the nurse emphasize?
Increased risk of hyperglycemia.
Greater risk of diabetic retinopathy.
Risk of thromboembolic events such as stroke.
Higher likelihood of diabetic ketoacidosis.
The Correct Answer is C
Educating a patient with atrial fibrillation requires applying knowledge of cardiac hemodynamics and the coagulation cascade. The nurse must focus on how ineffective atrial contractions lead to blood stasis, increasing the probability of clot formation and subsequent systemic embolization.
Choice A rationale
Atrial fibrillation does not directly cause hyperglycemia. While the stress of an acute arrhythmia might slightly elevate blood glucose due to cortisol release, it is not a primary complication or a major risk specifically linked to this rhythm.
Choice B rationale
Diabetic retinopathy is a microvascular complication resulting from chronic poor glucose control over many years. It is not exacerbated or caused by the onset of atrial fibrillation, which is a macrovascular and electrical conduction issue of the heart.
Choice C rationale
In atrial fibrillation, the atria quiver instead of contracting effectively, allowing blood to pool in the left atrial appendage. This stasis leads to thrombus formation; if a clot dislodges, it can travel to the brain.
Choice D rationale
Diabetic ketoacidosis is typically triggered by infection, insulin omission, or extreme physiological stress in Type 1 diabetics. While an arrhythmia is a stressor, the most specific and dangerous direct risk of atrial fibrillation remains systemic thromboembolism
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Evaluating a patient with liver failure involves understanding the biosynthetic pathways of coagulation. The liver produces vitamin K dependent clotting factors, and monitoring laboratory trends is essential to assess the severity of coagulopathy and the risk for spontaneous internal bleeding.
Choice A rationale
Urine output monitoring assesses renal perfusion and fluid balance, which is important in liver failure due to the risk of hepatorenal syndrome. However, it does not directly measure the liver ability to synthesize the essential factors needed for clotting.
Choice B rationale
Oxygen saturation measures the percentage of hemoglobin bound to oxygen in the blood. While respiratory status is important, it is not the priority assessment for a patient specifically at risk for hemorrhage due to impaired clotting factor synthesis.
Choice C rationale
Blood pressure can indicate hemodynamic stability and signs of shock if a bleed has already occurred. However, it is a late indicator of hemorrhage and does not provide information regarding the actual physiological capacity for blood coagulation.
Choice D rationale
The liver synthesizes factors I, II, VII, IX, and X. PT and INR directly measure the extrinsic pathway of coagulation. A normal PT is 11 to 13.5 seconds, and a normal INR is 0.8 to 1.1.
Correct Answer is D
Explanation
Delegating tasks to unlicensed personnel after spinal surgery requires knowledge of postoperative safety protocols. Applying principles of spinal immobilization and proper body mechanics is crucial to prevent vertebral misalignment, spinal cord injury, or surgical site complications during early mobilization phases.
Choice A rationale
Reporting a pain level of 6/10 is an appropriate action for unlicensed personnel as they are expected to communicate patient status to the nurse. This does not warrant intervention because it demonstrates adherence to reporting protocols for pain management.
Choice B rationale
Offering oral fluids is generally acceptable for postoperative clients once they are alert and have positive bowel sounds or gag reflexes. Unless the client is strictly NPO, this basic care task is within the scope of unlicensed assistive personnel.
Choice C rationale
Repositioning a spinal surgery client using a draw sheet and additional assistance is a safe method to ensure the spine remains neutral. This prevents shearing forces and maintains alignment, making it an appropriate action for the staff member.
Choice D rationale
Assisting a client to sit without logrolling risks twisting the spinal column, which can cause permanent nerve damage or dehiscence. Clients must be moved as a single unit to maintain neutral alignment during all movements following spinal surgery.
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