Stage 4 — Generate solutions. Tenecteplase has been administered and thrombectomy transfer is underway. Which nursing actions belong in the immediate plan? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
After thrombolysis, close neurologic and blood-pressure monitoring, aspiration prevention, bleeding precautions, and withholding antithrombotic therapy during the immediate restricted period reduce harm. Intramuscular injection increases bleeding risk, and thrombectomy evaluation should not wait for medication response.
Quick answer Monitor the brain and blood pressure, prevent aspiration, avoid bleeding triggers, and continue urgent thrombectomy transfer.
Why this is correct Thrombolysis introduces hemorrhage risk while the stroke still threatens neurologic function. Structured monitoring detects either improvement or dangerous deterioration quickly.
Easy analogy or mental picture After opening a blocked pipe, watch both flow and leaks: neurologic checks track reperfusion while bleeding precautions track the treatment hazard.
Memory hook After lysis: neuro, pressure, swallow, bleeding.
NCLEX decision rule Post-thrombolysis care is high surveillance with no unnecessary punctures or early antithrombotics; new symptoms are emergencies.
Why the other choices are wrong Intramuscular injection creates avoidable bleeding, and waiting for response can delay time-sensitive mechanical reperfusion.
References
12026 Guideline for the Early Management of Patients With Acute Ischemic StrokeRapid stroke recognition, thrombolysis, thrombectomy pathways, and early management
2Care of the Patient With Acute Ischemic StrokeNursing monitoring, dysphagia safety, neurologic deterioration, and post-procedure care
Case updateThe client receives prescribed thrombolytic therapy and remains aphasic with right hemiparesis while transfer for thrombectomy is coordinated.