# A 68-year-old client arrived with right-sided weakness, dysarthria, and facial droop that began 2 hours ago. CT shows no hemorrhage, the NIH Stroke Scale score is 12, and blood pressure is 188/102 mmHg. The provider is considering IV alteplase for acute ischemic stroke. Which nursing actions are appropriate? Select all that apply. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=368580&lang=en > language: en > subject: Medical Emergencies > category: PA ## Question A 68-year-old client arrived with right-sided weakness, dysarthria, and facial droop that began 2 hours ago. CT shows no hemorrhage, the NIH Stroke Scale score is 12, and blood pressure is 188/102 mmHg. The provider is considering IV alteplase for acute ischemic stroke. Which nursing actions are appropriate? Select all that apply. 1 Confirm the exact last-known-well time and rapidly complete the time-dependent eligibility assessment using the current stroke protocol 2 When blood pressure remains stable, give aspirin and prophylactic subcutaneous heparin immediately after the alteplase infusion and before follow-up brain imaging because the absence of symptoms excludes hemorrhage 3 Give prescribed IV antihypertensive therapy to reach below 185/110 mmHg before alteplase and maintain below 180/105 mmHg for 24 hours 4 Establish needed IV access before treatment when possible, perform protocol-defined neurologic and blood-pressure checks, and evaluate acute deterioration 5 Withhold antiplatelet and anticoagulant therapy for 24 hours until follow-up imaging excludes bleeding, and defer nonessential traumatic procedures 6 Review the history, medications, laboratory results, imaging, and blood pressure for alteplase exclusions and precautions using the current protocol ## Explanation IV alteplase is time dependent, so the nurse confirms last known well and supports rapid eligibility assessment (Choice 1). Blood pressure must be below 185/110 mmHg before treatment and maintained below 180/105 mmHg for 24 hours afterward (Choice 3). Establish necessary access before treatment when feasible, then perform frequent neurologic and blood-pressure monitoring and urgently evaluate findings that can indicate intracranial hemorrhage (Choice 4). Antiplatelet and anticoagulant therapy is generally withheld for the first 24 hours until follow-up imaging excludes hemorrhage, and nonessential traumatic procedures are deferred (Choice 5). Eligibility requires a current protocol-based review of clinical history, medications, tests, imaging, and blood pressure because exclusions and precautions are nuanced (Choice 6). Starting aspirin or heparin immediately after the infusion, before follow-up imaging, increases bleeding risk (Choice 2). ## In-depth explanation Acute Ischemic Stroke — Hyperacute Care 1. FAST/BEFAST recognition; last known well (LKW) verification 2. Non-contrast head CT to rule out hemorrhage 3. IV alteplase (tPA) within 4.5-hour window for eligible clients (some extended-window per imaging) 4. Mechanical thrombectomy candidacy if large-vessel occlusion (extended window up to 24 hr per imaging) 5. NIH Stroke Scale, BP control, glucose control 6. Avoid hyperthermia; control glucose; head of bed per facility protocol tPA Eligibility Highlights - Within 4.5 hr of LKW - Measurable neuro deficit - CT no hemorrhage - BP ≤185/110 (treat to control before infusion) - Age ≥18; some pediatric/geriatric considerations Major Absolute Contraindications - Intracranial hemorrhage - Recent intracranial or spinal surgery (≤3 months) - Recent stroke (≤3 months) - Active internal bleeding - Severe uncontrolled hypertension - Bleeding diathesis - Anticoagulant with elevated INR/PT/aPTT/anti-Xa - Recent major head trauma BP Targets - Pre-tPA: BP <185/110 (treat with labetalol or nicardipine) - Post-tPA × 24 hr: BP <180/105 - Avoid sudden BP drops (cerebral hypoperfusion) Post-Alteplase Monitoring × 24 hr - NIH Stroke Scale q15 min × 2 hr, then q30 min × 6 hr, then q1 hr × 16 hr - BP per the same schedule - HOLD antiplatelets/anticoagulants × 24 hr - HOLD invasive procedures (NG, Foley, arterial puncture) × 24 hr - Avoid IM injections - Sudden severe headache, decreased LOC, nausea, new deficit → STOP infusion + STAT head CT Memory Tip "LKW + CT + BP <185/110 + No bleeding contras; HOLD all anti-platelet/anticoag × 24 hr" ## Clinical scenario Scenario 68 yo, sudden right-sided weakness + slurred speech + facial droop, 2 hr from LKW, CT no hemorrhage, NIHSS 12, BP 188/102. Provider considering IV alteplase. Action Map 1. Verify LKW (within 4.5 hr) 2. BP control: pre-tPA <185/110; post-tPA <180/105 × 24 hr 3. Contraindication screen 4. Two large-bore IVs; continuous monitoring; NIHSS q15 min during infusion 5. ICH surveillance: severe HA, decreased LOC, nausea, new deficit 6. HOLD antiplatelet/anticoag × 24 hr; HOLD NG/Foley/arterial puncture; avoid IM Avoid - Aspirin/heparin within 24 hr of alteplase - Sudden BP drop - Missing the time window - Skipping contraindication screen ## Key concepts - **IV Alteplase (tPA) for Acute Ischemic Stroke** — Tissue plasminogen activator administered IV for eligible acute ischemic stroke clients to dissolve the occluding clot. Standard time window: within 4.5 hours of last known well; some clients with favorable advanced imaging may be candidates beyond. Major risks: intracranial hemorrhage, systemic bleeding, angioedema. Standard dose: 0.9 mg/kg (max 90 mg) — 10% bolus over 1 minute, remainder infused over 60 minutes. Strict BP control before and after, continuous neurologic monitoring, and bleeding precautions for 24 hours post-infusion. - **BP Targets and Time Window** — Pre-alteplase: BP must be ≤185/110 mmHg; treat with IV labetalol or nicardipine to achieve target before starting infusion. Post-alteplase × 24 hours: BP <180/105 mmHg with frequent monitoring (often q15 min × 2 hr, then q30 min × 6 hr, then q1 hr × 16 hr). Avoid sudden large drops in BP that cause cerebral hypoperfusion. Time window: ≤4.5 hours from last known well for standard candidates; mechanical thrombectomy may extend to 24 hours per advanced imaging when large-vessel occlusion is present. - **Post-Alteplase Bleeding Precautions** — For at least 24 hours after IV alteplase: HOLD antiplatelets (aspirin, clopidogrel) and anticoagulants; HOLD invasive procedures including NG tube placement, indwelling urinary catheter insertion, and arterial puncture; avoid intramuscular injections; minimize venipunctures and use small-gauge IVs already in place. Surveillance: monitor for signs of intracranial hemorrhage (sudden severe headache, decreased level of consciousness, nausea/vomiting, new neurologic deficit) — STOP infusion if active and obtain STAT head CT. Aspirin is typically started 24 hours after alteplase pending follow-up imaging. ## Related questions - [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=en) - [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=en) - [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=en) - [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=en) - [A 68-year-old client is admitted to the emergency department with suspected sepsis from a …](https://mymerci.kr/pages/nclex_q.php?qn_id=363987&lang=en) - [A nurse is caring for an adult client in the emergency department who is suspected to have…](https://mymerci.kr/pages/nclex_q.php?qn_id=363993&lang=en) - [A nurse is teaching a 72-year-old client with chronic heart failure (reduced ejection frac…](https://mymerci.kr/pages/nclex_q.php?qn_id=366202&lang=en) - [A nurse is caring for an adult client admitted with diabetic ketoacidosis. Laboratory resu…](https://mymerci.kr/pages/nclex_q.php?qn_id=366294&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=368580&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=368580&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=368580&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=368580&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=368580&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. Always follow current clinical guidelines and your institution’s protocols._