Nclexrn Quiz: Acute Stroke Priority Actions And Care

What this quiz covers

This quiz focuses on Acute Stroke Priority Actions And Care, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

How to use this quiz

Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

Question 1

1. Prepare the client for immediate noncontrast head computed tomography
2. Administer intravenous dextrose per hypoglycemia protocol and reassess neurologic status (correct answer)
3. Administer aspirin after confirming the client can swallow safely
4. Obtain a detailed last-known-well time from family and document

Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework uses ABCs and addresses reversible causes like hypoglycemia mimicking stroke. Administering intravenous dextrose per protocol and reassessing is the highest priority based on guidelines to correct hypoglycemia before further evaluation. Preparing for CT assumes stroke without ruling out mimics; aspirin is contraindicated until hemorrhage is excluded; obtaining last known well is important but secondary to treating low glucose. The decision-making principle is to treat hypoglycemia immediately as it can resolve symptoms. Guidelines mandate glucose check and correction in all suspected strokes. A transferable strategy is to always screen and correct metabolic abnormalities first in acute neuro presentations.

Question 2

1. Keep the client nothing by mouth until a bedside swallow screen is completed
2. Administer alteplase (tPA) now before obtaining head computed tomography (correct answer)
3. Obtain a noncontrast head computed tomography STAT
4. Draw labs including complete blood count and coagulation studies

Explanation: 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.

Question 3

1. Last known well time cannot be confirmed because the client arrived alone (correct answer)
2. Blood pressure 148/82 mmHg
3. History of carotid artery disease
4. SpO2 98% on room air

Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework assesses factors impacting thrombolytic eligibility. The unconfirmed last known well time requires immediate action based on guidelines, as it determines treatment window and needs clarification. Normal BP doesn't require action; history is a risk but not acute; normal SpO2 is fine. The decision-making principle is accurate timing for decisions. Guidelines use last known well for eligibility. A transferable strategy is to investigate and document onset details promptly to guide stroke management.

Question 4

1. Activate stroke alert and prepare for immediate noncontrast head computed tomography (correct answer)
2. Administer a sedative to decrease sympathetic stimulation and blood pressure
3. Delay imaging until blood pressure is normalized to prevent hemorrhage
4. Obtain a urine drug screen before initiating any stroke interventions

Explanation: 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.

Question 5

1. Provide fluids and encourage rest to treat possible dehydration
2. Administer the next scheduled anticoagulant dose to prevent recurrent stroke
3. Reassess neurologic status in 30 minutes to confirm the change
4. Notify the provider/stroke team immediately and prepare for emergent head computed tomography (correct answer)

Explanation: 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.

Question 6

1. Apply oxygen to maintain SpO2 at or above 94% and activate the stroke protocol (correct answer)
2. Administer the scheduled diuretic to improve oxygenation and reduce confusion
3. Obtain a complete set of intake and output data for the last 24 hours
4. Request a physical therapy consult for new weakness

Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework integrates ABCs with stroke protocol activation. Applying oxygen and activating protocol is the highest priority based on guidelines to optimize perfusion and enable rapid treatment. Administering diuretic assumes heart failure cause; obtaining I&O is secondary; PT consult follows diagnosis. The decision-making principle is addressing hypoxia first. Guidelines recommend SpO2 >=94% in strokes. A transferable strategy is to correct oxygenation while initiating stroke response in hypoxic patients with neuro changes.

Question 7

1. Administer prescribed opioid analgesia for headache relief
2. Activate stroke alert and prepare for immediate noncontrast head computed tomography (correct answer)
3. Dim the lights and place the client in a quiet room to reduce migraine triggers
4. Apply ice packs to the head and reassess pain in 30 minutes

Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework uses time-sensitive interventions for possible hemorrhagic stroke. Activating alert and preparing for CT is the highest priority based on guidelines to rule out bleed in severe headache with neuro deficits. Administering opioid is inappropriate without diagnosis; dimming lights assumes migraine; applying ice delays care. The decision-making principle is differentiating stroke types urgently. Guidelines prioritize imaging for thunderclap headaches. A transferable strategy is to treat severe headache with focal signs as potential hemorrhage and expedite diagnostics.

Question 8

1. Start an intravenous line and draw blood for coagulation studies while preparing for immediate imaging (correct answer)
2. Administer a benzodiazepine for anxiety to reduce blood pressure and heart rate
3. Perform a complete head-to-toe assessment before calling the stroke team
4. Give oral fluids to prevent dehydration prior to computed tomography

Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework involves ABCs and preparing for rapid diagnostics like imaging and labs. Starting an IV and drawing coagulation studies while preparing for imaging is the highest priority based on guidelines to enable timely thrombolysis if eligible. Administering benzodiazepine is not indicated for anxiety alone; complete assessment delays care; giving oral fluids risks aspiration. The decision-making principle is parallel processing to minimize door-to-treatment time. Guidelines recommend IV access and labs within 10 minutes of arrival. A transferable strategy is to multitask essential preparations like access and labs while expediting neuroimaging in acute stroke.

Question 9

1. Apply direct pressure to bleeding sites and notify the provider/stroke team of suspected bleeding complication (correct answer)
2. Administer aspirin to prevent additional clot formation
3. Encourage frequent tooth brushing to reduce gum bleeding
4. Ambulate the client to prevent venous thromboembolism

Explanation: 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.

Question 10

1. Notify the provider during rounds and continue to monitor neurologic status every 4 hours
2. Activate the facility's rapid response/stroke protocol and prepare for emergent transport to imaging (correct answer)
3. Administer the prescribed antibiotic early to prevent worsening infection-related delirium
4. Reorient the client and obtain a urine specimen to evaluate for urinary tract infection

Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework involves recognizing inpatient stroke symptoms and activating rapid response for time-sensitive interventions. Activating the rapid response/stroke protocol and preparing for emergent imaging is the highest priority based on guidelines to ensure quick diagnosis and treatment. Notifying during rounds delays care; administering antibiotics assumes infection without evidence; and reorienting with urine collection addresses delirium but not acute stroke. The decision-making principle is to treat sudden neuro changes as stroke until proven otherwise. Hospital protocols emphasize immediate activation for last known well under 24 hours. A transferable strategy is to document last known well time and escalate care immediately for any new focal deficits in hospitalized patients.

Question 11

1. Place the client in a high-Fowler position and suction oral secretions while applying oxygen (correct answer)
2. Obtain a detailed medication history to determine eligibility for thrombolytic therapy
3. Start an intravenous line and draw blood for coagulation studies
4. Prepare the client for immediate noncontrast head computed tomography

Explanation: 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.

Question 12

1. Schedule a speech therapy evaluation for communication strategies
2. Apply sequential compression devices to prevent deep vein thrombosis
3. Teach the family about stroke rehabilitation and expected recovery
4. Obtain the exact time the client was last known well and activate the stroke protocol (correct answer)

Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework focuses on time-sensitive stroke interventions starting with establishing last known well time. Obtaining the exact last known well time and activating the protocol is the highest priority based on guidelines to determine thrombolytic eligibility. Applying compression devices prevents DVT but is secondary; teaching family is for later; scheduling speech therapy addresses deficits post-diagnosis. The decision-making principle is accurate timing for the therapeutic window. American Stroke Association guidelines stress last known well for treatment decisions. A transferable strategy is to always confirm onset timing first to guide urgency in stroke evaluations.

Question 13

1. The exact time of symptom onset is unclear and family members are not yet reached (correct answer)
2. The client reports a history of hypertension
3. Blood glucose is within normal range
4. SpO2 is 96% on room air

Explanation: This question tests prioritization and clinical judgment in acute stroke care, focusing on eligibility for thrombolytic therapy. The priority framework involves time-sensitive stroke interventions, such as determining eligibility for tissue plasminogen activator (tPA) within the critical time window. The correct answer, unclear time of symptom onset with unreachable family members, is the highest priority because it directly impacts the ability to administer tPA within 4.5 hours, requiring immediate action to clarify the timeline. A history of hypertension is relevant but lower priority as the current blood pressure is below the threshold for tPA exclusion (less than 185/110 mmHg); normal blood glucose rules out hypoglycemia mimicking stroke but does not delay treatment; and SpO2 of 96% on room air is adequate and does not indicate immediate hypoxia requiring intervention. The decision-making principle follows American Heart Association guidelines, which emphasize rapid determination of last known well time to avoid missing the therapeutic window. Clinical judgment prioritizes resolving uncertainties that could exclude patients from life-saving interventions like thrombolysis. A transferable strategy for prioritizing care in acute stroke scenarios is to always address time-dependent factors first, such as symptom onset, before proceeding to other assessments like vital signs or lab values.

Question 14

1. Blood pressure 190/102 mmHg with acute vomiting and neurologic decline (correct answer)
2. Oxygen saturation 96% on room air
3. Heart rate 78/min
4. History of chronic kidney disease stage 2

Explanation: 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.

Question 15

1. Last known well time of 4 hours ago (correct answer)
2. Blood pressure 176/90 mmHg
3. Glucose 132 mg/dL
4. Oxygen saturation 98% on room air

Explanation: This question tests prioritization and clinical judgment in recognizing time-sensitive factors in acute stroke care. The priority framework is identifying barriers to time-sensitive interventions. The last known well time of 4 hours ago (option A) requires immediate action because it places the client outside the standard 3-hour window for IV thrombolytics, necessitating urgent evaluation for extended window therapy or mechanical thrombectomy eligibility. Option B (elevated BP) is expected in acute stroke; option C (mildly elevated glucose) doesn't preclude treatment; option D (normal oxygen saturation) is reassuring. The key principle is that time from symptom onset determines treatment eligibility, and clients presenting at 4-4.5 hours require expedited evaluation for extended window therapies. The transferable strategy is to recognize that last known well time is the most critical piece of information in acute stroke care, driving all subsequent treatment decisions.

Question 16

1. Keep the client nil per os and perform a bedside swallow screening
2. Initiate two large-bore intravenous lines and draw blood for laboratory tests per stroke protocol (correct answer)
3. Administer aspirin immediately to reduce platelet aggregation
4. Place the client in Trendelenburg position to improve cerebral perfusion

Explanation: This question tests prioritization and clinical judgment in acute stroke care during the initial emergency department evaluation. The priority framework is establishing vascular access and obtaining critical laboratory data for stroke protocol. Initiating two large-bore IVs and drawing blood for laboratory tests (option B) is the highest priority because it enables rapid administration of medications if needed and obtains essential labs (coagulation studies, glucose, platelets) required before thrombolytic decisions. Option A (NPO/swallow screening) is important but not the immediate priority; option C (aspirin) is contraindicated before brain imaging rules out hemorrhage; option D (Trendelenburg) is contraindicated as it increases intracranial pressure. The guiding principle is to establish vascular access and obtain critical labs simultaneously with imaging to expedite treatment decisions. The transferable strategy is to prioritize interventions that enable rapid treatment while avoiding those that could cause harm before diagnosis is confirmed.

Question 17

1. Delay imaging until the client is calm to avoid motion artifact
2. Apply physical restraints to prevent the client from leaving the stretcher
3. Provide a detailed explanation of computed tomography and ask the client to sign consent
4. Implement fall precautions, keep the client in bed, and expedite stroke protocol evaluation (correct answer)

Explanation: 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.

Question 18

1. Administer nothing by mouth and request a speech therapy swallow evaluation
2. Obtain consent for thrombolytic therapy and start the infusion
3. Perform a full cranial nerve assessment and document baseline findings
4. Place the client in a lateral position and suction the airway as needed (correct answer)

Explanation: 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.

Question 19

1. SpO2 of 97% on room air
2. Blood pressure above the client's baseline
3. History of prior gastrointestinal bleed
4. New severe headache with acute change in level of consciousness (correct answer)

Explanation: 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.

Question 20

1. Activate the rapid response/stroke alert and prepare for emergent stroke evaluation
2. Administer oral juice or glucose gel to treat hypoglycemia and then reassess neurologic status (correct answer)
3. Request an order for a sedative to reduce agitation during neurologic assessment
4. Obtain a complete set of neurologic checks every 4 hours

Explanation: 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.