Author Question: A client is receiving an infusion of tissue plasminogen activator (t-PA). The nurse assesses the ... (Read 65 times)

Engineer · **on:** Jun 25, 2018

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.

Question 2

A client has an intra-arterial blood pressure monitoring line. The nurse notes bright red blood on the client's sheets. What action should the nurse perform first?

a. Assess the insertion site.
b. Change the client's sheets.
c. Put on a pair of gloves.
d. Assess blood pressure.

jordangronback · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

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.

Answer to Question 2

ANS: C
For the nurse's safety, he or she should put on a pair of gloves to prevent blood exposure. The other actions are appropriate as well, but first the nurse must don a pair of gloves.