The nurse is teaching a client with atrial fibrillation about the need to begin long-term anticoagulant therapy. Which explanation should the nurse use to best describe the reasoning for this therapy?

"Because of the dysrhythmia, blood backs up in the legs and puts you at risk for blood clots."

"Because the atria are quivering, blood flows sluggishly through them, and clots can form along the heart wall, which then could loosen and travel to the lungs or brain."

"The medications that you are taking cause blood clots as a side effect so you need this medication to prevent them."

Answer and Explanation

The Correct Answer is B

Choice A reason: The statement "Because of the dysrhythmia, blood backs up in the legs and puts you at risk for blood clots" is incorrect. Atrial fibrillation primarily causes blood to pool in the atria, not the legs.

Choice B reason: The statement "Because the atria are quivering, blood flows sluggishly through them, and clots can form along the heart wall, which then could loosen and travel to the lungs or brain" accurately explains the risk of clot formation in atrial fibrillation and the importance of anticoagulant therapy to prevent strokes and other complications.

Choice C reason: The statement "The medications that you are taking cause blood clots as a side effect so you need this medication to prevent them" is incorrect. Anticoagulant therapy in atrial fibrillation is used to prevent clot formation due to the arrhythmia itself, not as a counteraction to the side effects of other medications.

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Correct Answer is A

Explanation

Choice A reason: A patient with a new-onset of confusion and restlessness is a priority because these symptoms could indicate a serious condition such as hypoxia, electrolyte imbalance, or a neurological event like a stroke. These changes in mental status need to be evaluated immediately to prevent further complications.

Choice B reason: Dizziness after receiving captopril (Capoten) can be a side effect of the medication due to its blood pressure-lowering effects. While it should be monitored, it is not as urgent as the new-onset confusion and restlessness seen in another patient.

Choice C reason: A patient requiring oxygen via nasal cannula with saturations of 97% is stable as the oxygen saturation is within normal limits. This patient does not need to be prioritized over others with more acute symptoms.

Choice D reason: A patient who has received digoxin and has a blood pressure of 100/56 should be monitored, especially for signs of digoxin toxicity. However, this situation is not as critical as the new-onset confusion and restlessness in another patient.

A. Mild headaches B. Cloudiness that worsens at night C. Severe eye pain D. Mild eye pain

Correct Answer is C

Explanation

Choice A reason: Mild headaches are not typically associated with increased intraocular pressure. While headaches can accompany eye conditions, they are not as common or specific as severe eye pain in this context.

Choice B reason: Cloudiness that worsens at night could be related to cataracts or other eye conditions but is not a specific manifestation of increased intraocular pressure. Severe eye pain is a more direct indicator of conditions like acute angle-closure glaucoma.

Choice C reason: Severe eye pain is a significant clinical manifestation of increased intraocular pressure, such as in acute angle-closure glaucoma. This condition can lead to sudden, severe eye pain due to the rapid rise in intraocular pressure, which can damage the optic nerve if not treated promptly.

Choice D reason: Mild eye pain may occur in various minor eye conditions but is not as indicative of serious issues like increased intraocular pressure. Severe eye pain is more concerning and requires immediate assessment and intervention.

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The nurse is teaching a client with atrial fibrillation about the need to begin long-term anticoagulant therapy. Which explanation should the nurse use to best describe the reasoning for this therapy?

Nursing Test Bank

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