Question

The client who experienced an ischemic stroke is halfway finished with an altepase(t-PA) infusion when he suddenly complains of an excruciating headache. What is the best nursing action? A. Slow the transfusion of TPA and reassess in 10 minutes B. Obtain a set of vital signs and ensure TPA IV patency C. Stop the TPA and notify the neurologist D. Stop the TPA and lower the head of the bed

Short answer

Answer: The best nursing action is to stop the TPA infusion and notify the neurologist immediately for proper evaluation and management of the potential complication.

Step-by-step solution

Understand the situation and roles of alteplase

Alteplase (t-PA) is a medication used to treat ischemic stroke by breaking down blood clots. During administration, any sign of complications, such as headache, should be considered seriously as it can be an indication of bleeding or other serious issues. Nurses play a crucial role in monitoring the patient during alteplase administration.

Analyze each option provided

A. Slowing the transfusion and reassessing in 10 minutes may not address the urgent issue of a potential complication. B. Obtaining vital signs and ensuring IV patency does not address the possibility of a serious complication. C. Stopping the TPA and notifying the neurologist is a fast and appropriate response as it immediately addresses the potential issue and alerts the healthcare provider responsible for the client's care. D. Stopping the TPA and lowering the head of bed doesn't involve informing a healthcare provider for an appropriate response.

Identify the best nursing action

Based on a thorough analysis of each option, the best nursing action in this case is C: Stop the TPA and notify the neurologist. As we mentioned, this option directly addresses the potential complications of alteplase administration and ensures the appropriate healthcare provider is informed immediately for proper evaluation and management.