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When Assessing a Patient with a Possible Stroke, the Nurse

Question 9

Multiple Choice

When assessing a patient with a possible stroke, the nurse finds that the patient's aphasia started 3.5 hours previously and the blood pressure is 170/92 mm Hg. Which of these orders by the health care provider should the nurse question?


A) Infuse normal saline at 75 mL/hr.
B) Keep head of bed elevated at least 30 degrees.
C) Administer tissue plasminogen activator ( tPA ) per protocol.
D) Titrate labetalol ( Normodyne ) drip to keep BP less than 140/90 mm Hg.

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