What is the nurse’s first action at this time when a client who had thrombolytic therapy is receiving a continuous infusion of sodium heparin?

Stop the heparin infusion immediately

P. 840, Physiological Integrity Based on the assessment data, the nurses first action should be to stop the heparin infusion, because the change in vital signs is consistent with bleeding. Heparin is an anticoagulant and increases the clients risk for bleeding. The client may be bleeding internally, so symptoms of bleeding on assessment may not be overt. Simply decreasing the infusion rate will still lead to anticoagulation of the blood and increase the clients risk for further bleeding. Documentation is always an important nursing action but, in this case of suspected bleeding, documentation can wait until after the heparin infusion is stopped.