Difficulty: Medium
Average Score: 64%
Simulated
The nurse has been made aware of the following client situations. The nurse should first assess the client
Correct answer
A
Rationale
Oozing at the tPA insertion site (A) suggests bleeding risk, a critical complication due to thrombolytic therapy, requiring immediate assessment. Oliguria in AKI (B), pericarditis pain relief (C), and migraine with vomiting (D) are less urgent.