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. Deep palpation of the abdomen is contraindicated in clients with an AAA, as it may cause rupture.
B. A chest X-ray may detect an aneurysm, but it is not the priority assessment.
C. Pain assessment is important, as sudden severe pain could indicate rupture, but it is not the first priority.
D. Blood pressure assessment is the priority, as hypertension can increase the risk of aneurysm rupture. Strict BP control is critical to preventing complications.

A. Hyperkalemia B. Hypoglycemia C. Seizures D. Cardiac dysrhythmias

Correct Answer is D

Explanation

A. Hyperkalemia is not a typical complication of thiazide diuretics. Instead, they promote potassium loss, increasing the risk of hypokalemia.
B. Hypoglycemia is not directly associated with thiazide diuretics. These medications may affect glucose tolerance but do not cause low blood sugar.
C. Seizures are not a common adverse effect of thiazide diuretics. While severe electrolyte imbalances could contribute to neurological symptoms, they are not the primary concern in this scenario.
D. Cardiac dysrhythmias can result from hypokalemia, a common side effect of thiazide diuretics. Potassium is essential for normal cardiac conduction, and low levels can lead to palpitations, weakness, and potentially life-threatening arrhythmias.

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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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Naxlex Comprehensive Predictor Exams

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Explanation

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