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. NSTEMI (Non-ST Elevation Myocardial Infarction) does not present with ST-segment elevation on the ECG. Instead, it shows ST-segment depression or T-wave inversion and is diagnosed with elevated cardiac biomarkers.
B. Stable angina is predictable chest pain that occurs with exertion and is relieved by rest or nitroglycerin. It does not cause acute ECG changes.
C. Unstable angina is characterized by chest pain that occurs at rest or with minimal exertion and is not relieved by nitroglycerin. However, it does not show ST-segment elevation or myocardial infarction markers.
D. STEMI (ST-Elevation Myocardial Infarction) is diagnosed when there is ST-segment elevation in two or more contiguous ECG leads, indicating complete occlusion of a coronary artery and requiring immediate intervention such as percutaneous coronary intervention (PCI) or thrombolytic therapy.

A. Avoid sick contacts B. You will require prophylactic antibiotics prior to dental procedures. C. You can discontinue your antibiotics once you start feeling better. D. Avoid physical activity for the next six months to allow your heart to heal completely.

Correct Answer is B

Explanation

A. Avoiding sick contacts is generally a good practice, but it is not the primary concern for a client with infective endocarditis. The focus is on preventing bacterial infections that could enter the bloodstream and affect the heart valves.
B. Prophylactic antibiotics are required before dental and invasive procedures to prevent bacterial endocarditis recurrence. The bacteria that cause infective endocarditis can enter the bloodstream through procedures that involve mucosal surfaces.
C. Discontinuing antibiotics when feeling better is incorrect. Infective endocarditis requires a full course of IV antibiotics, often lasting 4 to 6 weeks, to fully eradicate the infection and prevent complications.
D. Avoiding physical activity for six months is unnecessary unless the client has severe cardiac complications. However, clients should monitor for symptoms such as fatigue and consult their provider before engaging in strenuous activities.

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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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