A patient is receiving tissue plasminogen activator (tPA) for the treatment of an ischemic stroke. Which of the following is a priority intervention for this patient?
1. monitor for renal stone formation
2. reposition every 15 minutes
3. monitor for signs of bleeding
4. insert a nasogastric tube for nutritional support
3
Rationale: Abnormal bleeding is a complication of tPA therefore the nurse should monitor for signs of bleeding. Renal stone formation is not a complication of this medication. Frequent moving and placing any catheter or device into the patient can increase the risk of bleeding therefore the patient should not be repositioned every 15 minutes and a nasogastric tube should not be inserted.
You might also like to view...
When assessing vulnerable populations, a community health nurse uses a model that involves environmental resources. Which of the following would the nurse include?
A) Employment B) Social networks C) Access to health care D) Housing
The nurse is caring for a child with erythema multiforme (Stevens-Johnson syndrome). What local manifestations does the nurse expect to assess in this child? (Select all that apply.)
a. Papular urticaria b. Erythematous papular rash c. Lesions absent in the scalp d. Lesions enlarge by peripheral expansion e. Firm papules that may be capped by vesicles
The nurse can distinguish delirium from dementia by knowing which of the following?
A) Delirium has an acute onset and is progressive in course. B) Delirium has a gradual onset and can be resolved. C) Dementia has a gradual onset and is progressive in course. D) Dementia has an acute onset and can be resolved.
List three goals of client teaching
What will be an ideal response?