A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question?
a. Keep head of bed elevated at least 30 degrees.
b. Infuse normal saline intravenously at 75 mL/hr.
c. Administer tissue plasminogen activator (tPA) per protocol.
d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
ANS: D
Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be administered if the patient meets the other criteria for tPA use.
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