The nurse is caring for a postoperative patient who is receiving alteplase tPA (Activase) after developing a blood clot. The nurse notes a heart rate of 110 beats per minute and a blood pressure of 90/60 mm Hg. The nurse will perform which action?
a. Ask the patient about itching or shortness of breath.
b. Assess the surgical dressing for bleeding.
c. Evaluate the patient's urine output and fluid intake.
d. Recheck the patient's vital signs in 15 minutes.
ANS: B
Tachycardia and hypotension indicate bleeding. The nurse should check the patient's surgical dressing to assess for bleeding. These signs do not indicate anaphylaxis. They may indicate dehydration, but bleeding is the more likely cause of fluid volume deficit. The nurse should continue to evaluate vital signs, but it is imperative that the nurse assess the patient to explore the potential cause.
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