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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