The patient receives reteplase (Retavase) intravenously (IV). The nurse assesses the patient for orientation and level of consciousness. The patient's wife asks the nurse why this is being done. What does the nurse indicate as the reason for the assessment?
1. The medication can alter fluid balance; this affects orientation and level of consciousness.
2. The medication can cause bleeding in the brain; this affects orientation and level of consciousness.
3. The medication causes hypoglycemia; this affects orientation and level of consciousness.
4. The medication decreases oxygen to the brain; this decreases orientation and level of consciousness.
2
Rationale 1: Reteplase (Retavase) does not alter fluid balance in the body.
Rationale 2: Cerebral hemorrhage is a concern with reteplase (Retavase) therapy; the nurse must assess for changes in mental and neurological status.
Rationale 3: Reteplase (Retavase) does not cause hypoglycemia.
Rationale 4: Reteplase (Retavase) does not decrease oxygen to the brain.
Global Rationale: Cerebral hemorrhage is a concern with reteplase (Retavase) therapy; the nurse must assess for changes in mental and neurological status. Reteplase (Retavase) does not decrease oxygen to the brain. Reteplase (Retavase) does not cause hypoglycemia. Reteplase (Retavase) does not alter fluid balance in the body.
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