An adult is 2 hours post-tenecteplase for acute ischemic stroke. Classify each action for care during the first 24 hours.
Matrix
Choose your responses, then check the answer.
Explanation
Protocol neurologic and blood pressure monitoring and maintaining blood pressure below 180/105 mm Hg are scheduled first-24-hour care. Antiplatelet or anticoagulant therapy is withheld until follow-up imaging excludes hemorrhage, and avoidable invasive tubes are delayed because they can provoke bleeding. Sudden headache, vomiting, neurologic decline, or tongue and airway swelling requires immediate escalation.
Correct Answer Rows 1 and 2 are scheduled monitoring, rows 3 and 4 should be delayed or avoided until the safety checkpoint, and rows 5 and 6 require urgent escalation.
Why It Fits Thrombolysis care combines tight surveillance, avoidance of preventable bleeding, and rapid recognition of hemorrhage or angioedema.
Clinical Picture A stable baseline does not remove risk. The nurse continues protocol checks and reacts immediately to a new neurologic or airway change.
Memory Link Monitor on schedule, delay what can bleed, escalate any new brain or airway warning.
NCLEX Rule During the first 24 hours, use the post-thrombolysis protocol and follow-up imaging checkpoint rather than routine medication or invasive-device timing.
Why the Alternatives Fail Early aspirin and avoidable invasive tube placement add bleeding risk. Waiting for the next scheduled assessment is unsafe when severe headache, decline, tongue swelling, or stridor appears.
Sources
12026 AHA/ASA Acute Ischemic Stroke Guideline
22026 NCLEX-RN Test Plan
Blood pressure is 172/98 mm Hg and neurologic findings match the immediate post-treatment baseline. The client remains at risk for hemorrhage, angioedema, and aspiration.