# 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.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=568849&lang=en  
> language: en  
> subject: Pharmacological and Parenteral Therapies  
> category: PPT

## Question

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.

1

Perform frequent neurologic and blood-pressure assessments according to the stroke protocol

2

Maintain aspiration precautions and keep the client NPO until swallowing is screened

3

Avoid antiplatelet and anticoagulant therapy until the prescribed post-thrombolysis interval and imaging review

4

Minimize invasive procedures and observe all access sites for bleeding

5

Administer an intramuscular analgesic for the severe headache because oral medication is unsafe

6

Delay transfer to thrombectomy-capable care until the full neurologic response to tenecteplase is known

## 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.

## In-depth explanation

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

## Clinical scenario

Case update
The client receives prescribed thrombolytic therapy and remains aphasic with right hemiparesis while transfer for thrombectomy is coordinated.

## Related questions

- [A nurse is programming a high-alert IV medication on a smart infusion pump. Which actions …](https://mymerci.kr/pages/nclex_q.php?qn_id=372863&lang=en)
- [A patient has a serum potassium of 2.8 mEq/L and a new order for IV potassium chloride 40 …](https://mymerci.kr/pages/nclex_q.php?qn_id=373128&lang=en)
- [A patient on chronic phenytoin for seizure disorder reports new diplopia and unsteady gait…](https://mymerci.kr/pages/nclex_q.php?qn_id=373129&lang=en)
- [A patient on day 2 of total parenteral nutrition (TPN) has a capillary glucose of 248 mg/d…](https://mymerci.kr/pages/nclex_q.php?qn_id=373881&lang=en)
- [A nurse is teaching a patient newly started on metoprolol 25 mg twice daily for hypertensi…](https://mymerci.kr/pages/nclex_q.php?qn_id=374879&lang=en)
- [A patient post-radical cystectomy with ileal conduit urinary diversion is being taught uro…](https://mymerci.kr/pages/nclex_q.php?qn_id=374924&lang=en)
- [A nurse is teaching a patient discharged on oral potassium chloride (extended-release tabl…](https://mymerci.kr/pages/nclex_q.php?qn_id=374939&lang=en)
- [A 72-year-old on chronic warfarin for atrial fibrillation comes for routine follow-up. Aft…](https://mymerci.kr/pages/nclex_q.php?qn_id=374949&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=568849&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=568849&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=568849&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=568849&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=568849&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._