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Anticoagulation with warfarin is contraindicated in hemorrhagic stroke because it increases the risk of further bleeding.

Early ambulation is appropriate in ischemic stroke rehabilitation but contraindicated in acute SAH due to the risk of rebleeding and increased intracranial pressure.

An endotracheal airway may be required if the client cannot maintain their airway, but it is not a routine intervention for all SAH patients.

Elevating the head of the bed helps reduce intracranial pressure and risk of aspiration, making it an appropriate intervention.

Normal saline infusion maintains hydration and cerebral perfusion without altering osmolarity, which is safe.

tPA is indicated for ischemic stroke within a 4.5-hour window, provided there are no contraindications; this client is within 3.5 hours, so the order is appropriate.

An oxygen saturation of 91% is acceptable for a COPD client, as their target range is typically 88–92%.

Bibasilar crackles suggest fluid or mucus accumulation but are not as immediately life-threatening as hypoventilation.

The tripod position is a compensatory mechanism to ease breathing in COPD and is expected during dyspnea.

Adding PEEP is used to improve oxygenation and prevent alveolar collapse, not to correct increased inspiratory pressure.

Disconnected tubing would cause low-pressure alarms, not high inspiratory pressures.

Increasing humidifier temperature maintains moisture in inspired air but does not resolve elevated inspiratory pressures.

Sedation would worsen hypoventilation and CO₂ retention, making the condition worse.

Oral fluids may help with secretion mobilization but will not correct acute respiratory acidosis.

Sodium bicarbonate is indicated for metabolic acidosis, not respiratory acidosis.

Elevating the head of bed to 60 degrees is not appropriate because excessive elevation can decrease cerebral perfusion pressure (CPP) by reducing systemic blood flow to the brain. Optimal positioning is usually 30 degrees.

Documentation should always occur, but when values are within acceptable ranges, ongoing monitoring takes priority over simple charting.

Reporting to the healthcare provider is necessary only if CPP is critically low (<50 mmHg) or ICP is dangerously elevated (>20 mmHg). In this case, the values are acceptable, so immediate reporting is unnecessary.

A portable chest x-ray is often ordered to confirm tube placement, but it is not the immediate corrective action when unilateral breath sounds are noted.

Advancing the tube would worsen the problem, since the tube is already too deep and likely in the right mainstem bronchus.

A pulmonologist is not required for reintubation unless there are complications; this is a common issue that can be corrected without reintubation.

A client who had a transient ischemic attack (TIA) yesterday and is due for aspirin needs attention, but this is not as urgent as administering time-sensitive thrombolytic therapy.

A client with subarachnoid hemorrhage 2 days ago receiving nimodipine (to prevent vasospasm) is important, but the situation is not as time-sensitive as tPA administration.

A client with atrial fibrillation and a new order for warfarin requires initiation of anticoagulation to prevent embolic stroke, but the urgency is lower compared with immediate tPA administration in an acute stroke.

Suction pressure is regulated in the suction control chamber, not the water seal chamber, so tidaling does not indicate excessive suction.

Continuous bubbling in the water seal chamber, not tidaling, indicates an air leak in the system.

Gravity drainage helps remove fluid, but this occurs in the collection chamber, not the water seal chamber.

Bradycardia is not a typical sign of barotrauma; cardiovascular collapse may occur with tension pneumothorax, but tachycardia is more common initially.

Hypertension is not associated with barotrauma; instead, hypotension may occur due to impaired venous return if a pneumothorax develops.

Bronchial breath sounds throughout the lung fields may occur with lung consolidation (e.g., pneumonia), but this is not characteristic of barotrauma.