The nurse is caring for a client who received tissue plasminogen activator 2 hours ago. The nurse would be most concerned by which of the following in the client?
Rationale: Tissue plasma activator (tPA) is used to dissolve clots in certain clients who have experienced a stroke or myocardial infarction. Blood in the stool or any other sign of bleeding (LOC changes, hypotension, and tachycardia) may indicate a hemorrhage and is an emergency situation. The other choices do not indicate an emergency situation that would be caused by the administration of tPA.
