Final answer:
The first action the nurse should take is to stop the infusion of alteplase, as the symptoms may indicate a serious side effect such as intracranial hemorrhage. Immediate assessment and notifying the healthcare provider are also crucial steps following this intervention.
Step-by-step explanation:
When a client receiving alteplase, a thrombolytic agent, shows signs of confusion and inability to follow commands, the nurse must first consider these symptoms as potentially serious signs of neurological changes. Quick assessment and intervention are crucial.
Given the situation described, the first action the nurse should take is to stop the infusion. Alteplase can cause bleeding, including intracranial hemorrhage, which can present as an acute change in mental status. The nurse should subsequently check the client's vital signs, assess for other symptoms of bleeding or stroke, and notify the healthcare provider immediately. Checking the client's pupils for changes can also be a part of the rapid neurological assessment, which can provide valuable diagnostic information about the patient's brain function. While it is important to reorient the client to ensure safety, stopping the infusion to limit potential complications is the priority. After all immediate assessments and actions have taken place, such as monitoring vital signs and neurological status, further instructions from the healthcare provider can be expected.