 A nurse is preparing to administer thrombolytic therapy to a client who had

an ischemicstroke. Which of the following is an appropriate nursing action?

-Start the therapy within 8 hrs. (within 6 hrs.)

-Insert an indwelling urinary catheter after therapy begins

-Monitor blood pressure every 30 minutes during infusion.

-Elevate the head of the bed between 25 and 30 degrees (to reduce ICP &

promote venousdrainage, ATI page 89)

 A nurse is teaching a client about the use of an incentive spirometer. Which of

the followinginstructions should the nurse include in the teaching?

-Place hands on the upper abdomen during inhalation.

-Exhale slowly through pursed lips.

-Hold breath about 3 to 5 seconds before exhaling. (ATI page 138)

-Position the mouthpiece 2.5 cm (1 in) from the mouth.

 A nurse is assessing a client who is 12 hr. postoperative following a colon

resection. Which ofthe following findings should the nurse report to the surgeon?

-Heart rate 90/mm

-Hgb 8.2 g/dL

-Gastric ph of 3.0

-Absent bowel sounds

Recall that bowel sounds are altered in patients with obstruction; absent bowel