A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the client to be disoriented to person, place, and time. What action by the nurse is best?
a. Assess the client's pupillary responses.
b. Request a neurologic consultation.
c. Stop the infusion and call the provider.
d. Take and document a full set of vital signs.
ANS: C
A change in neurologic status in a client receiving t-PA could indicate intracranial hemorrhage. The nurse should stop the infusion and notify the provider immediately. A full assessment, including pupillary responses and vital signs, occurs next. The nurse may or may not need to call a neurologist.
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