Question

question 7 of 20
a nurse is reevaluating a client receiving iv fibrinolytic therapy. which finding requires
immediate intervention by the nurse?

chest pain 2 of 10 (on a 1 - to - 10 pain scale)

altered level of consciousness.

presence of reperfusion dysrhythmias

minimal oozing of blood from the iv site

Explanation:

• Chest pain of 2/10 is mild and not an immediate concern.
• Reperfusion dysrhythmias are expected during fibrinolytic therapy as they indicate reperfusion.
• Minimal oozing from IV site is common with anticoagulant/fibrinolytic use and not urgent.
• Altered level of consciousness can indicate intracranial hemorrhage, a life - threatening complication of fibrinolytic therapy, requiring immediate intervention.

Answer:

B. Altered level of consciousness.