During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status at least every cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow?

A. 15-30g oral carbohydrates:
Oral carbohydrates are a first-line treatment for hypoglycemia in a conscious, alert patient who can safely swallow. However, since the patient is unresponsive, administering oral carbohydrates is not an appropriate option. The patient’s inability to swallow safely increases the risk of aspiration, making IV treatment the priority in this case.

B. 10% dextrose continuous IV infusion:
A 10% dextrose IV infusion can be used in the management of hypoglycemia, but in an acute, emergency setting where the patient is unresponsive and their blood glucose is critically low (30 mg/dL), a rapid-acting intervention is needed. A bolus dose of a concentrated solution, such as 50% dextrose, is more appropriate for quickly raising the blood glucose level in this situation, rather than a continuous infusion, which takes longer to achieve an effective increase in glucose.

C. Glucagon PO:
Glucagon is typically used for hypoglycemia in patients who are unconscious or unable to take oral glucose. However, glucagon is typically administered intramuscularly (IM) or subcutaneously (SQ), not orally (PO). Administering glucagon orally is ineffective, as it would not be absorbed by the body in the necessary manner to correct hypoglycemia. Therefore, this option is inappropriate.

D. 50% dextrose in water (50% DW) IV push:
When a patient is unresponsive and their blood glucose level is critically low (30 mg/dL), the priority treatment is an immediate, concentrated source of glucose. Administering 50% dextrose IV push is the most appropriate intervention in this scenario. It provides a rapid and effective increase in blood glucose levels, which is critical for reversing hypoglycemia in an emergency situation. This is the fastest and most direct approach to treating severe hypoglycemia in an unresponsive patient.

A) "Administer IV hydralazine and monitor blood pressure":
. The patient's elevated blood pressure (172/92 mmHg), along with headaches and blurred vision, could indicate a hypertensive emergency, a serious condition where extremely high blood pressure can cause acute organ damage. Hydralazine is a common intravenous antihypertensive medication used to lower blood pressure quickly in these situations. The nurse should administer hydralazine as prescribed and closely monitor the blood pressure to prevent complications like stroke, heart failure, or kidney damage. Blood pressure management is the priority, as the patient's symptoms are likely related to the elevated BP.

B) "Administer oxygen at 10 liters/minute by non-rebreather mask":
. While oxygen therapy may be appropriate for patients with respiratory distress or hypoxia, the patient's SpO2 is 97% on room air, indicating that there is no immediate oxygenation issue. Administering oxygen unnecessarily could lead to oxygen toxicity, and it is not the priority in this case. The patient's main concern is their elevated blood pressure, which requires urgent management.

C) "Administer acetaminophen 650 mg PO re-check temperature":
. While headaches are one of the patient's complaints, there is no indication of fever (the temperature is 98.6°F). Administering acetaminophen would be appropriate for pain relief, but it is not the priority in this case. The elevated blood pressure and potential hypertensive emergency are the primary issues that need to be addressed first.

D) "Infuse 0.9% sodium chloride at 120 mL/hour":
. Normal saline (0.9% sodium chloride) is typically used for hydration, but there is no indication that the patient is dehydrated or that intravenous fluids are the priority. In cases of hypertensive emergency, the goal is to lower blood pressure using antihypertensive medications, not to infuse fluids. Fluid administration could potentially worsen the situation if the elevated blood pressure is not addressed first.