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 A

Explanation

A. Counting the number of QRS complexes in a 6-second strip and multiplying by 10 provides an estimate of the heart rate per minute.
B. Measuring T waves is used to assess repolarization abnormalities, not to determine heart rate.
C. While the monitor provides a heart rate reading, manual calculation is essential for verifying accuracy.
D. P waves indicate atrial activity but are not used to calculate the overall heart rate.

A. "Cardiac Rehab will help you get back to normal." B. "The cardiac rehab program can help you safely return to an active lifestyle." C. "It's normal to feel that way at first, but once you learn the routine, you'll enjoy it." D. "Your doctor is the expert and would only recommend what is best for you."

Correct Answer is B

Explanation

A. While cardiac rehab does help recovery, this statement does not emphasize the safety and long-term benefits of supervised rehabilitation.
B. Providing education about the role of cardiac rehab is essential. Cardiac rehab monitors the client's progress and helps safely return them to an active lifestyle.
C. While this statement acknowledges the client's feelings, it does not provide enough information about the benefits of cardiac rehab.
D. This response is too authoritative and does not address the client’s concerns or autonomy.

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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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Explanation

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Explanation

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