During the first 24 hours after a patient has received fibrinolytic therapy, which of the following is a priority nursing intervention?
1. administer pain medications
2. maintain strict intake and output
3. monitor level of consciousness
4. assess for pulmonary emboli
3
Rationale: The first 24 hours after fibrinolytic administration holds the highest risk for intracranial hemorrhage. The nurse should administer pain medications as prescribed and assess for pulmonary emboli. Monitoring intake and output also is a nursing priority however the intervention that has the highest priority for the first 24 hours after fibrinolytic therapy is assessing level of consciousness.
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