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Acute Stroke: Priority Actions And Care - NCLEX Rn

  1. A 63-year-old client with hypertension and hyperlipidemia arrives to the emergency department 50 minutes after sudden onset of right-sided weakness. Assessment: BP 150/86 mmHg, HR 80/min, RR 16/min, SpO2 97% on room air; blood glucose 90 mg/dL (normal 70–110). The client is anxious and repeatedly asks for water but has a wet, gurgly voice. Which intervention should the nurse implement FIRST?
    Answer: Keep the client nothing by mouth and perform a bedside swallow screen when stable This question tests prioritization and clinical judgment in acute stroke care. The priority framework addresses aspiration risk with ABCs in mind. Keeping NPO and performing swallow screen is the highest priority based on guidelines to prevent pneumonia in dysphagic patients. Giving sips risks aspiration; providing meds with applesauce is unsafe without screening; supine position may worsen perfusion. The decision-making principle is safety in oral intake. Guidelines recommend swallow evaluation before anything by mouth. A transferable strategy is to assess swallowing early in all stroke clients with speech or voice changes.
  2. A 63-year-old client with a history of transient ischemic attacks, carotid artery stenosis, and hypertension arrives to the emergency department with facial droop and inability to speak. The spouse reports the client was last known well 3 hours ago. Assessment: follows simple commands, expressive aphasia, right-sided weakness, BP 172/88 mmHg, HR 84/min, RR 16/min, oxygen saturation 97% on room air; glucose 98 mg/dL (normal 70–110). Which intervention should the nurse implement FIRST in response to the client's symptoms?
    Answer: Initiate two large-bore intravenous lines and draw blood for laboratory tests per stroke protocol In acute stroke, the immediate priority is to establish vascular access and obtain critical laboratory values to expedite potential thrombolytic decisions. Initiating two large-bore IV lines and drawing blood for tests allows rapid medication administration and provides essential data (coagulation, glucose, platelets) needed before any treatment. Swallow screening is important but not the first step; it follows initial stabilization. Administering aspirin is contraindicated until brain imaging rules out hemorrhage. Trendelenburg positioning increases intracranial pressure and is harmful. Thus, the action that simultaneously supports diagnosis and treatment is the priority.
  3. A 69-year-old client with hypertension, hyperlipidemia, and coronary artery disease arrives to the emergency department 4 hours after sudden onset of left-sided weakness. Assessment: BP 170/92 mmHg, HR 76/min, RR 18/min, SpO2 97% on room air; blood glucose 100 mg/dL (normal 70–110). The provider prescribes alteplase. Which assessment finding requires IMMEDIATE action before proceeding?
    Answer: Platelet count 68,000/mm³ (normal 150,000–400,000/mm³) This question tests prioritization and clinical judgment in acute stroke care. The priority framework assesses contraindications before thrombolysis, such as bleeding risks. The low platelet count requires immediate action based on guidelines, as it's a contraindication for tPA due to hemorrhage risk. High cholesterol is a risk factor but not acute; elevated BP may need management but isn't prohibitive; normal SpO2 doesn't require action. The decision-making principle is ensuring safety criteria for high-risk interventions. American Heart Association lists thrombocytopenia under 100,000 as exclusion. A transferable strategy is to review labs for absolute contraindications before proceeding with thrombolytics in stroke.
  4. A 79-year-old client on a medical-surgical unit is admitted for pneumonia and is improving; history includes type 2 diabetes and hypertension. The nurse finds the client suddenly difficult to arouse with new left facial droop and left arm weakness; last known well was 20 minutes ago. Assessment: BP 164/90 mmHg, HR 96/min, RR 22/min, oxygen saturation 92% on 2 L/min nasal cannula, glucose 62 mg/dL (normal 70–110). What is the nurse's PRIORITY action for this client?
    Answer: Administer oral juice or glucose gel to treat hypoglycemia and then reassess neurologic status This question tests prioritization and clinical judgment in acute stroke care, specifically addressing stroke mimics and reversible causes. The priority framework is ABCs and identifying/treating reversible causes of neurologic symptoms. Administering oral glucose or glucose gel (option B) is the highest priority because the client's glucose of 62 mg/dL is critically low and hypoglycemia can mimic stroke symptoms exactly. Option A (stroke alert) would be appropriate after correcting hypoglycemia if symptoms persist; option C (sedation) is contraindicated and would mask neurologic assessment; option D (routine checks) fails to address the acute change. The key principle is that hypoglycemia must be ruled out or treated immediately in any patient with acute neurologic changes, as it's a rapidly reversible cause. The transferable strategy is to always check glucose first in acute neurologic changes and treat hypoglycemia before pursuing stroke workup, as correction may completely resolve symptoms.
  5. A 66-year-old client arrives to the emergency department 30 minutes after sudden onset of right arm weakness and difficulty speaking. History includes hypertension, hyperlipidemia, and obesity. Assessment: drooling, wet/gurgly voice, unable to handle oral secretions, oxygen saturation 89% on room air, RR 26/min, BP 170/94 mmHg, HR 102/min. What is the nurse's PRIORITY action for this client?
    Answer: Place the client in a high-Fowler position and suction oral secretions while applying oxygen This question tests prioritization and clinical judgment in acute stroke care using the ABC priority framework. The priority is addressing airway compromise and hypoxia before proceeding with stroke evaluation. Placing the client in high-Fowler position, suctioning secretions, and applying oxygen (option A) is the highest priority because the client has signs of aspiration risk (drooling, wet voice, inability to handle secretions) and hypoxia (SpO2 89%). Option B (medication history) is important but not before stabilizing ABCs; option C (IV access) follows airway management; option D (CT scan) cannot safely proceed with an unstable airway. The guiding principle is that airway protection and oxygenation always take precedence over diagnostic procedures in acute care. The transferable strategy is to recognize aspiration risk in stroke patients and prioritize airway protection before pursuing time-sensitive stroke interventions.
  6. A 76-year-old client is 3 hours post-alteplase for ischemic stroke. The nurse notes the client is suddenly lethargic and has new right pupil dilation. Assessment: BP 204/110 mmHg, HR 60/min, RR 10/min, SpO2 94% on room air. What is the nurse's PRIORITY action?
    Answer: Notify the provider/stroke team immediately and prepare for emergent head computed tomography This question tests prioritization and clinical judgment in acute stroke care. The priority framework monitors for post-tPA complications like increased intracranial pressure. Notifying the team and preparing for CT is the highest priority based on guidelines for signs of herniation or bleed. Administering anticoagulant risks worsening; reassessing delays; providing fluids assumes dehydration. The decision-making principle is rapid imaging for deterioration. Guidelines recommend emergent evaluation for pupil changes. A transferable strategy is to prioritize neuroimaging and escalation for any acute post-treatment neuro decline.
  7. A 57-year-old client with hypertension and cocaine use history arrives to the emergency department 1 hour after sudden left-sided weakness and slurred speech. Assessment: BP 210/112 mmHg, HR 104/min, RR 20/min, SpO2 96% on room air; blood glucose 97 mg/dL (normal 70–110). What is the nurse's PRIORITY action?
    Answer: Activate stroke alert and prepare for immediate noncontrast head computed tomography This question tests prioritization and clinical judgment in acute stroke care. The priority framework emphasizes not delaying imaging despite comorbidities like drug use. Activating alert and preparing for CT is the highest priority based on guidelines to diagnose quickly regardless of BP. Administering sedative is not first-line; delaying for BP normalization risks time; drug screen is secondary. The decision-making principle is time-sensitive diagnosis. Guidelines allow imaging with high BP. A transferable strategy is to proceed with protocol activation even in complex cases like substance use.
  8. A 79-year-old client with hypertension, atrial fibrillation, and prior stroke arrives to the emergency department 70 minutes after sudden onset of right-sided weakness. Assessment: BP 160/90 mmHg, HR 118 irregular, RR 18/min, SpO2 95% on room air; blood glucose 103 mg/dL (normal 70–110). The nurse is preparing the client for possible thrombolytic therapy. Which intervention should the nurse implement FIRST?
    Answer: Ensure two large-bore intravenous lines are in place and draw ordered labs promptly During an acute stroke evaluation, the first priority is to prepare for possible thrombolytic therapy. This requires reliable IV access and baseline laboratory studies. Ensuring two large-bore IV lines and promptly drawing ordered labs directly supports safe tPA administration and monitoring. Administering aspirin is contraindicated until a CT scan rules out hemorrhagic stroke, because aspirin increases bleeding risk. Aggressively lowering blood pressure is harmful; permissive hypertension is often maintained to preserve cerebral perfusion, and oral antihypertensives are not an emergency first-line intervention. Offering a meal tray is dangerous because the client must remain NPO to prevent aspiration and allow emergent procedures; glucose is normal, so hypoglycemia is not an immediate concern. Thus, securing IV access and labs is the correct first action.
  9. A 71-year-old client received alteplase for acute ischemic stroke 2 hours ago. History includes hypertension and diabetes. The nurse notes oozing at the intravenous site and new gum bleeding. Assessment: BP 152/88 mmHg, HR 92/min, RR 18/min, SpO2 97% on room air; neurologic status unchanged from baseline. What is the nurse's PRIORITY action?
    Answer: Apply direct pressure to bleeding sites and notify the provider/stroke team of suspected bleeding complication This question tests prioritization and clinical judgment in acute stroke care. The priority framework monitors for bleeding post-thrombolysis. Applying pressure and notifying the team is the highest priority based on guidelines for managing hemorrhage complications. Administering aspirin worsens bleeding; encouraging brushing irritates sites; ambulating risks falls. The decision-making principle is prompt intervention for coagulopathy signs. Guidelines advise stopping anticoagulants and supportive care. A transferable strategy is to inspect sites frequently and escalate any bleeding post-tPA.
  10. A 68-year-old client arrives to the emergency department 45 minutes after sudden onset of right-sided arm weakness and slurred speech. History includes atrial fibrillation (not consistently taking anticoagulant), hypertension, and smoking; last known well time is 45 minutes ago. Assessment: alert but dysarthric, facial droop on the right, right arm drift, glucose 110 mg/dL (normal 70–110), BP 188/96 mmHg, HR 108 irregular, RR 18/min, oxygen saturation 96% on room air. What is the nurse's PRIORITY action for this client?
    Answer: Activate the facility stroke alert and prepare the client for immediate noncontrast head computed tomography This question tests prioritization and clinical judgment in acute stroke care. The priority framework here is time-sensitive stroke interventions, as the client presents within the critical time window for potential thrombolytic therapy. Activating the stroke alert and obtaining immediate noncontrast head CT (option B) is the highest priority because it initiates the stroke protocol and determines whether the stroke is ischemic or hemorrhagic, which guides all subsequent treatment decisions. Option A (ECG) is important but not the immediate priority; option C (swallow screening) must wait until after acute interventions; option D (lowering BP) is contraindicated before imaging as it could reduce cerebral perfusion in acute stroke. The key principle is that time is brain tissue - every minute counts in acute stroke care. The transferable strategy is to recognize stroke symptoms and immediately activate the stroke protocol to expedite imaging and treatment decisions within the therapeutic window.
  11. A 66-year-old client received intravenous thrombolytic therapy for an ischemic stroke 1 hour ago. History includes hypertension and prior gastrointestinal bleed. The client now reports a sudden severe headache and becomes increasingly confused. Assessment: BP 190/102 mmHg, HR 84/min, RR 16/min, SpO2 97% on room air; pupils unequal compared with baseline. Which assessment finding requires IMMEDIATE action?
    Answer: New severe headache with acute change in level of consciousness This question tests prioritization and clinical judgment in acute stroke care. The priority framework involves monitoring for complications post-thrombolysis, such as intracranial hemorrhage. The new severe headache with acute change in level of consciousness requires immediate action based on guidelines, indicating possible bleed needing urgent intervention. Elevated blood pressure is common but not immediately actionable alone; history of GI bleed is a risk but not new; SpO2 97% is normal. The decision-making principle is vigilant monitoring for hemorrhage signs post-tPA. American Heart Association guidelines recommend stopping infusion and obtaining emergent CT for deterioration. A transferable strategy is to prioritize reassessment and escalation for any sudden worsening after thrombolytics in stroke care.
  12. A 75-year-old client with a history of transient ischemic attacks, carotid stenosis, and hypertension arrives to the emergency department 30 minutes after sudden facial droop and inability to speak. Assessment: follows commands with right hand only, left arm flaccid, BP 158/86 mmHg, HR 82/min, RR 16/min, SpO2 98% on room air; blood glucose 92 mg/dL (normal 70–110). Which intervention should the nurse implement FIRST?
    Answer: Obtain the exact time the client was last known well and activate the stroke protocol Acute stroke care is time-based: the critical next step is to establish the exact time the client was last known well and to activate the stroke protocol, because thrombolysis and endovascular treatment decisions are calculated from that time. The blood glucose is normal and vital signs are stable, so the priority is moving through the stroke pathway. Requesting a speech therapy consult for communication strategies may be useful after the evaluation, but it does not address urgent reperfusion eligibility. Applying sequential compression devices is a DVT-prevention measure that may be appropriate after diagnosis, but it is not the first action during an acute stroke. Family teaching about stroke rehabilitation and expected recovery is important for discharge planning, but it is premature until the diagnosis and plan are established. The first action must preserve the treatment window by confirming last-known-well time and activating the stroke protocol.
  13. A 59-year-old client with hyperlipidemia and prior transient ischemic attack arrives to the emergency department 2 hours after sudden onset of left facial droop and aphasia. Assessment: unable to follow commands, drooling, gurgling voice, BP 164/92 mmHg, HR 88/min, RR 22/min, SpO2 91% on room air, blood glucose 82 mg/dL (normal 70–110). Which intervention should the nurse implement FIRST in response to the client's symptoms?
    Answer: Place the client in a lateral position and suction the airway as needed This question tests prioritization and clinical judgment in acute stroke care. The priority framework focuses on ABCs, particularly airway protection in clients with potential aspiration risk due to dysphagia. Placing the client in a lateral position and suctioning as needed is the highest priority based on clinical guidelines to prevent aspiration pneumonia and maintain oxygenation. Obtaining consent for thrombolytics is premature without imaging; performing a full cranial nerve assessment is lower priority than airway; and keeping NPO with speech evaluation addresses swallowing but not immediate airway compromise. The decision-making principle is to address life-threatening issues like airway obstruction first. Guidelines from the American Stroke Association emphasize early airway management in stroke patients with bulbar symptoms. A transferable strategy is to assess and secure the airway before other interventions in stroke clients showing signs of respiratory distress or secretion issues.
  14. A 58-year-old client with atrial fibrillation and hypertension arrives to the emergency department 1 hour after sudden onset of right arm weakness and expressive aphasia. Assessment: BP 168/90 mmHg, HR 124 irregular, RR 20/min, SpO2 95% on room air; temperature 98.6°F (37.0°C); blood glucose 110 mg/dL (normal 70–110). What is the nurse's PRIORITY action?
    Answer: Start an intravenous line and draw blood for coagulation studies while preparing for immediate imaging In acute stroke, the priority is rapid, parallel preparation for imaging and potential thrombolysis. Starting an IV and drawing coagulation studies while preparing for immediate imaging directly supports guideline-based time goals and does not delay care. Administering a benzodiazepine for anxiety is not indicated: it can sedate the patient, obscure neurologic assessment, and unnecessary blood-pressure reduction may worsen cerebral perfusion. Performing a complete head-to-toe assessment before activating the stroke team wastes critical minutes; the nurse should initiate the stroke protocol immediately while doing a focused examination. Giving oral fluids, even with routine medications, is unsafe because a stroke patient must remain NPO to prevent aspiration and to allow emergent thrombolysis or surgery; routine medications are withheld until bleeding risk and imaging results are known. Thus, only the option that combines IV access, laboratory preparation, and rapid imaging readiness meets the urgent needs of acute ischemic stroke.
  15. A 68-year-old client with a history of hypertension, atrial fibrillation (not taking anticoagulants), type 2 diabetes, and smoking arrives to the emergency department 45 minutes after sudden right-sided arm weakness and slurred speech began. Assessment: awake, answers slowly, facial droop on the right, right arm drift, blood glucose 98 mg/dL (normal 70–110), BP 188/96 mmHg, HR 112 irregular, RR 18/min, SpO2 96% on room air. What is the nurse's PRIORITY action for this client?
    Answer: Activate the stroke alert and prepare the client for immediate noncontrast head computed tomography. The 45-minute onset places the client in the acute stroke treatment window, so the priority is to activate the stroke pathway and obtain a noncontrast head CT that distinguishes ischemic stroke from hemorrhage. That distinction determines whether thrombolysis is an option. Giving aspirin first is incorrect because it assumes an ischemic stroke; if hemorrhage is present, aspirin will worsen bleeding, and a swallow screen does not rule out hemorrhage. Lowering blood pressure to below 140/90 before imaging is also incorrect: aggressive BP reduction can lower cerebral perfusion and is not the safest action before CT results are available. Taking a detailed history before head imaging is useful later but is not the priority; it wastes treatment time. The key decision is to move immediately to imaging and stroke team activation, because delayed diagnosis directly reduces the chances of a good outcome.
  16. A 72-year-old client is receiving post-thrombolytic monitoring after intravenous alteplase for ischemic stroke. History includes hypertension and chronic kidney disease stage 2. Two hours after completion of alteplase, the client develops sudden nausea and vomiting with worsening neurologic status; assessment shows BP 190/102 mmHg, HR 78/min, RR 18/min, oxygen saturation 96% on room air, and new unequal pupils. Which assessment finding requires IMMEDIATE action?
    Answer: Blood pressure 190/102 mmHg with acute vomiting and neurologic decline This question tests prioritization and clinical judgment in recognizing post-thrombolytic complications in acute stroke care. The priority framework is identifying life-threatening hemorrhagic transformation after alteplase. The blood pressure of 190/102 mmHg with acute vomiting and neurologic decline (option A) requires immediate action because these findings strongly suggest intracranial hemorrhage, a life-threatening complication of thrombolytic therapy requiring emergent intervention. Options B (normal oxygen saturation) and C (normal heart rate) are stable findings; option D (chronic kidney disease history) is relevant but not an acute concern. The key principle is that hypertension with neurologic deterioration after thrombolytics indicates hemorrhagic conversion requiring immediate blood pressure control and reversal agents. The transferable strategy is to recognize the triad of hypertension, vomiting, and neurologic decline as hemorrhagic transformation requiring immediate intervention to prevent death.
  17. A 71-year-old client presents to the emergency department 2 hours after sudden onset of left-sided weakness and slurred speech. History includes hypertension, type 2 diabetes, and prior gastrointestinal bleeding. Assessment: NIH Stroke Scale score 10, BP 178/92 mmHg, HR 90/min, RR 18/min, oxygen saturation 96% on room air; glucose 140 mg/dL (normal 70–110); platelet count 210,000/mm³ (normal 150,000–400,000), international normalized ratio (INR) 1.1 (normal 0.8–1.2). The provider prescribes several orders. The nurse should QUESTION which order related to stroke management?
    Answer: Administer aspirin 325 mg by mouth now before brain imaging is obtained This question tests prioritization and clinical judgment in acute stroke care, specifically identifying contraindicated orders. The priority framework is recognizing unsafe medication orders that could cause patient harm. The nurse should question administering aspirin before brain imaging (option C) because aspirin is absolutely contraindicated before CT scan rules out hemorrhagic stroke, as it could worsen bleeding. Option A (alteplase after CT confirms no hemorrhage) is appropriate; option B (NPO status) is standard safety protocol; option D (immediate CT) is the correct priority action. The key principle is that no antithrombotic or antiplatelet medications should be given before brain imaging confirms the stroke type. The transferable strategy is to recognize that in acute stroke, brain imaging must always precede any medication that affects coagulation or platelet function to prevent catastrophic hemorrhage.
  18. A 70-year-old client with hypertension and hyperlipidemia presents to the emergency department 3 hours after sudden left-sided weakness and slurred speech began. Assessment: BP 212/110 mmHg, HR 78/min, RR 18/min, SpO2 96% on room air, blood glucose 102 mg/dL (normal 70–110). The provider writes orders for suspected acute ischemic stroke. The nurse should QUESTION which order related to stroke management?
    Answer: Administer alteplase (tPA) now before obtaining head computed tomography This question tests prioritization and clinical judgment in acute stroke care. The priority framework emphasizes time-sensitive interventions and verifying orders against evidence-based protocols. The nurse should question administering alteplase before CT, as guidelines require ruling out hemorrhage first to avoid catastrophic complications. Keeping NPO until swallow screen prevents aspiration but is standard; obtaining CT STAT is essential; drawing labs is routine for eligibility. The decision-making principle is safety in thrombolytic administration. American Heart Association guidelines contraindicate tPA without confirmatory imaging. A transferable strategy is to always verify imaging results before initiating high-risk therapies in suspected strokes.
  19. A 58-year-old client with a history of transient ischemic attacks and hypertension arrives to the emergency department 35 minutes after sudden facial droop and difficulty speaking. Assessment: BP 146/84 mmHg, HR 80/min, RR 18/min, SpO2 97% on room air; blood glucose 89 mg/dL (normal 70–110). The client is restless and tries to get out of bed. What is the nurse's PRIORITY action?
    Answer: Implement fall precautions, keep the client in bed, and expedite stroke protocol evaluation This question tests prioritization and clinical judgment in acute stroke care. The priority framework balances safety with time-sensitive evaluation. Implementing fall precautions and expediting protocol is the highest priority based on guidelines to prevent injury while advancing care. Applying restraints is inappropriate; detailed explanation delays; delaying imaging risks outcomes. The decision-making principle is patient safety during agitation. Guidelines emphasize non-restraint methods. A transferable strategy is to use least restrictive measures for safety while prioritizing stroke diagnostics in restless patients.
  20. A 61-year-old client with a history of transient ischemic attacks and carotid artery disease arrives to the emergency department 40 minutes after sudden right facial droop and word-finding difficulty. Assessment: BP 148/82 mmHg, HR 78/min, RR 16/min, SpO2 98% on room air; blood glucose 88 mg/dL (normal 70–110). Which assessment finding requires IMMEDIATE action?
    Answer: Last known well time cannot be confirmed because the client arrived alone In acute ischemic stroke, thrombolytic therapy is time-limited, and eligibility is anchored to the last known well time. A client who arrives alone with an unconfirmed last known well time creates a gap that must be closed immediately by contacting family, witnesses, or records, because it determines whether the client can receive alteplase within the treatment window. The blood pressure of 148/82 mmHg is mildly elevated but is well below the threshold (typically >185/110 mmHg) that requires urgent blood-pressure management in acute stroke, so it does not demand immediate action. The documented history of carotid artery disease and prior transient ischemic attacks is a significant risk factor but is background information; it does not change the immediate plan. An oxygen saturation of 98% on room air is normal and requires no intervention. Of the four findings, only the unconfirmed last known well time threatens the client's chance of thrombolysis, making it the one that requires immediate action.

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