Acute Stroke: Priority Actions And Care - NCLEX Rn

What is the priority nursing action before giving anything by mouth to an acute stroke patient?

Perform a swallow screen (dysphagia screening). Detects dysphagia early to prevent aspiration pneumonia from oral intake in at-risk patients.
What oxygenation target is appropriate in acute stroke to avoid routine hyperoxia?

Supplement oxygen only if hypoxic; maintain $SpO_2\geq94\%$ . Prevents potential harm from hyperoxia, which may increase oxidative stress and worsen ischemic brain injury.
Which medication is first-line for suspected increased intracranial pressure from cerebral edema?

Mannitol or hypertonic saline (per protocol/provider order). Osmotic agents reduce cerebral edema by drawing fluid from brain tissue into the bloodstream.
Which in-hospital tool quantifies stroke severity for trending and communication?

NIH Stroke Scale (NIHSS). Offers a standardized, objective measure of neurologic deficits for monitoring changes and guiding decisions.
What is the time goal for completing initial noncontrast head CT after ED arrival?

Within $20$ minutes of arrival. Enables rapid stroke type differentiation to meet guidelines for timely thrombolytic eligibility assessment.
Which blood pressure threshold generally requires treatment before giving IV alteplase?

BP must be $<185/110$ mm Hg before alteplase. Elevated pressures heighten the risk of hemorrhagic complications during thrombolytic administration.
What is the maximum time window from last known well for IV alteplase in eligible patients?

Up to $4.5$ hours (selected patients). Evidence from trials supports benefit in improving outcomes for eligible ischemic stroke patients within this period.
Which prehospital action most directly speeds definitive acute stroke treatment?

Activate stroke alert and pre-notify the receiving ED. Mobilizes hospital stroke team and resources for expedited evaluation and intervention upon patient arrival.
Which imaging study is used to identify large-vessel occlusion for thrombectomy decisions?

CT angiography (CTA) of head and neck. Detects occlusions in major vessels to guide decisions on endovascular thrombectomy eligibility.
What is the required timing of follow-up brain imaging after IV alteplase before antithrombotics?

Repeat CT or MRI at $24$ hours. Confirms absence of hemorrhage to safely initiate antithrombotic therapy without exacerbating bleeding.
Which positioning action best reduces aspiration risk in an acute stroke patient with dysphagia?

Keep head of bed elevated (about $30^\circ$ ) and NPO until cleared. Elevation minimizes reflux and aspiration risk, while NPO status ensures safety until swallowing is assessed.
What is the typical door-to-needle goal time for IV thrombolysis in acute ischemic stroke?

Within $60$ minutes of ED arrival. Minimizes ischemic duration to optimize neuronal preservation and functional recovery per guidelines.
Which complication is a top early priority to prevent in immobile acute stroke patients?

Venous thromboembolism (DVT/PE). Immobility promotes venous stasis, increasing risk of thrombosis and potentially fatal pulmonary embolism.
What is the priority imaging test to differentiate ischemic vs hemorrhagic stroke?

Noncontrast head CT. Rapidly rules out hemorrhage, which is essential before initiating thrombolytic therapy for ischemic stroke.
What is the typical time window for mechanical thrombectomy in selected large-vessel occlusion?

Up to $24$ hours in selected patients. Imaging-based selection extends the window for patients with viable tissue, improving outcomes.
Which scale is commonly used for rapid prehospital stroke screening?

FAST (Face, Arm, Speech, Time). Facilitates quick identification of common stroke signs to ensure prompt transport to appropriate care.
What is the immediate nursing action if severe headache and vomiting occur during alteplase?

Stop alteplase infusion and obtain emergent head CT. These symptoms suggest possible intracranial hemorrhage, necessitating immediate cessation and diagnostic imaging.
What is the correct alteplase dosing for acute ischemic stroke?

$0.9\ \text{mg/kg}$ (max $90$ mg); $10\%$ bolus then $90\%$ over $60$ min. Standard dosing based on weight ensures effective thrombolysis while minimizing overdose risks.
What is the single most important history element to establish in suspected acute stroke?

Last known well (time symptoms were last normal). Determines the onset time critical for eligibility in time-sensitive treatments like thrombolysis and thrombectomy.
Which intervention prevents DVT in acute stroke when pharmacologic prophylaxis is not yet safe?

Intermittent pneumatic compression devices. Mechanical compression enhances venous flow, reducing stasis when anticoagulants are contraindicated.
What is the first nursing priority when a stroke patient has decreased level of consciousness?

Airway protection (maintain airway and oxygenation). Prevents hypoxia and aspiration in patients with compromised protective reflexes due to altered consciousness.
Which bedside glucose finding must be corrected before labeling deficits as stroke?

Hypoglycemia (low blood glucose). Can mimic stroke symptoms with focal deficits that resolve upon correction, avoiding misdiagnosis.
After IV alteplase, what blood pressure target should be maintained to reduce bleeding risk?

Maintain BP $<180/105$ mm Hg. Strict control post-thrombolysis reduces the likelihood of intracranial bleeding complications.
Which medication class is avoided for $24$ hours after IV alteplase unless ordered otherwise?

Antiplatelets and anticoagulants. These agents increase bleeding risk in the vulnerable period following thrombolytic therapy.
Identify the priority action when a stroke patient suddenly becomes more confused and drowsy.

Reassess neurologic status and activate urgent provider/rapid response for repeat imaging. Sudden changes may indicate deterioration like edema or hemorrhage, requiring prompt evaluation and imaging.

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