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56-year-old client presents with sudden onset of stroke-like symptoms that started 45 minutes prior to admission. Presenting National Institute of Health Stroke Scale (NIHSS) Score = 20. Head CT negative for blood. Past medical history includes hypertension treated with an ACE inhibitor. Alteplase 68 mg IV, given over one hour.

At the end of the alteplase infusion, the nurse notes that the client's tongue was swollen. What is the nurse's priority action?

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Answer:

The nurse should  give antihistamine or administer epinephrine. This is because the swollen tongue is a sign of allergic reactions(although not a sign of stroke) due  to intake of  Angiotensin-converting enzymes (ACE) Inhibitors, by the patients,needed to  dilate the narrow blood vessels. The  drugs increase blood flow, but this comes with an allergic reactions.In case the swelling is much, which might occlude air passage  leading  to respiratory distress, intubation with insertion of endotrachea tube (ET) through the mouth might be needed).to open the airways by connection to the ventilators,

Explanation:

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