Scenario: A 70-year-old patient diagnosed with a hemorrhagic stroke was admitted 1 day ago. His medical history includes hypertension, osteoarthritis, and type 2 diabetes mellitus. He has right-sided paralysis, garbled speech, and a weak cough reflex. This morning he is very restless. Vital signs: Blood pressure 140/80, pulse 110, respirations 24. Oxygen saturation is 90%.
NGN Item Type: Take Action
Use an X to indicate which actions listed in the left column would be implemented to prevent complications in this patient.
Actions implemented
– Administer subcutaneous heparin.
– Implement seizure precautions.
-Apply oxygen via cannula at 2 L/min.
– Consult with the dietician to provide the patient with a diabetic diet.
– Position the patient on his right side for no longer than 2 hours.
-Perform passive ROM exercises.
– Elevate head of bed 45 degrees.
Rationale: Provide a rationale for each of your selection
