# Place the nursing actions in order for a client arriving 35 minutes after sudden aphasia and right-sided weakness. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=395468&lang=en > language: en > subject: Establishing Priorities > category: MOC ## Question Place the nursing actions in order for a client arriving 35 minutes after sudden aphasia and right-sided weakness. Assist with eligibility and contraindication review and prepare the selected thrombolytic or thrombectomy pathway as ordered Activate the stroke alert and notify the imaging and stroke teams without waiting to see whether deficits resolve Prepare for urgent noncontrast brain imaging and prescribed vascular imaging without delaying reperfusion evaluation While the team mobilizes, establish the exact last-known-well time and obtain anticoagulant, bleeding, surgery, and baseline-function history Perform rapid airway, breathing, circulation, neurologic, vital-sign, oxygenation, and point-of-care glucose assessment ## Explanation Stabilize and rapidly exclude a glucose mimic, then activate the stroke system immediately. Determine last-known-well and bleeding or anticoagulant risks while the team mobilizes. Obtain urgent imaging to distinguish hemorrhage and define vascular targets. The stroke team then selects the appropriate reperfusion pathway; nursing preparation should not introduce avoidable delay. ## In-depth explanation Correct sequence Rapid ABC, neuro, and glucose check → stroke activation → time and contraindication history → urgent imaging → reperfusion pathway. 2026 focus Time remains critical, but treatment selection depends on clinical deficits, imaging, time from last known well, and individual eligibility rather than a single memorized clock rule. NCLEX decision rule Do not wait for spontaneous improvement. Activate the system and gather decision-critical data in parallel.References 1AHA/ASA 2026 acute ischemic stroke guideline 2AHA: 2026 guideline highlights ## Clinical scenario Acute stroke pathway The client is breathing spontaneously and point-of-care glucose testing is available. The treatment team follows the 2026 AHA/ASA acute ischemic stroke guideline and local stroke protocol. ## Key concepts - **Last Known Well** — The latest verified time at which the client was at the neurologic baseline. - **Reperfusion Therapy** — Treatment intended to restore cerebral blood flow, such as intravenous thrombolysis or mechanical thrombectomy in eligible clients. - **Stroke Mimic** — A condition such as hypoglycemia that can resemble acute stroke and must be recognized rapidly. ## Related questions - [A nurse in a busy emergency department is triaging five clients who arrive simultaneously.…](https://mymerci.kr/pages/nclex_q.php?qn_id=368320&lang=en) - [At shift change, a charge nurse receives six postoperative reports. Classify the timing of…](https://mymerci.kr/pages/nclex_q.php?qn_id=393410&lang=en) - [Review the nurse's escalation timeline for a postoperative client whose condition is deter…](https://mymerci.kr/pages/nclex_q.php?qn_id=393500&lang=en) - [The nurse receives report on four clients. Which client should the nurse assess first?](https://mymerci.kr/pages/nclex_q.php?qn_id=393675&lang=en) - [Four hours after open reduction and internal fixation of a fractured tibia, a client repor…](https://mymerci.kr/pages/nclex_q.php?qn_id=394047&lang=en) - [The nurse receives reports on four clients. Which client should the nurse assess first?](https://mymerci.kr/pages/nclex_q.php?qn_id=394076&lang=en) - [During a mass casualty incident, which client should be assigned a delayed priority rather…](https://mymerci.kr/pages/nclex_q.php?qn_id=394136&lang=en) - [During disaster triage, a client is not breathing after the airway is opened and repositio…](https://mymerci.kr/pages/nclex_q.php?qn_id=394166&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=395468&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=395468&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=395468&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=395468&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=395468&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._