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 C

Explanation

A. An echocardiogram does not assess coronary artery blockages; a coronary angiogram or cardiac catheterization is used for that.
B. Fasting is not required for a standard transthoracic echocardiogram. However, fasting may be needed for a transesophageal echocardiogram (TEE).
C. An echocardiogram is a non-invasive ultrasound test that evaluates heart structure, valve function, and cardiac muscle performance.
D. There is no discomfort during a transthoracic echocardiogram, as it is performed externally using a probe on the chest.

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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