# An adult is 2 hours post-tenecteplase for acute ischemic stroke. Classify each action for care during the first 24 hours. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=568932&lang=en > language: en > subject: Potential for Alterations in Body Systems > category: ROR ## Question An adult is 2 hours post-tenecteplase for acute ischemic stroke. Classify each action for care during the first 24 hours. | | Scheduled first-24-hour monitoring | Delay or avoid until follow-up imaging or an urgent indication | Urgent escalation | | --- | --- | --- | --- | | Maintain blood pressure below 180/105 mm Hg during the first 24 hours | | | | | Continue protocol neurologic and blood pressure assessments even if symptoms improve | | | | | Administer routine aspirin 2 hours after thrombolysis before follow-up imaging | | | | | Insert a nasogastric or urinary catheter now for convenience when no urgent indication exists | | | | | Respond to sudden severe headache, vomiting, or new neurologic decline | | | | | Respond to new tongue swelling, stridor, or difficulty breathing | | | | ## 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. ## In-depth explanation 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 ## Clinical scenario 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. ## Key concepts - **dysphagia screen** — Bedside swallow assessment (water swallow, voice quality) before oral intake post-stroke. - **permissive hypertension** — Allowing higher BP early in ischemic stroke to maintain penumbra perfusion. - **VTE prophylaxis** — SCDs immediately, heparin/LMWH 24+ hours post-tPA, lifelong if AF. ## Related questions - [For each clinical scenario, select the corresponding 2022 ACC/AHA/HFSA heart-failure stage…](https://mymerci.kr/pages/nclex_q.php?qn_id=393413&lang=en) - [An adult is 2 hours post-tenecteplase for acute ischemic stroke. Classify each action for …](https://mymerci.kr/pages/nclex_q.php?qn_id=393414&lang=en) - [An immobile adult with dysphagia is on hospital day 4 after acute ischemic stroke. Classif…](https://mymerci.kr/pages/nclex_q.php?qn_id=393415&lang=en) - [A client admitted with an acute stroke coughs and develops a wet voice during the initial …](https://mymerci.kr/pages/nclex_q.php?qn_id=395564&lang=en) - [Two hours after a lower-leg fracture is immobilized, the client reports escalating pain de…](https://mymerci.kr/pages/nclex_q.php?qn_id=395612&lang=en) - [A hospitalized client develops early acute kidney injury after several days of vomiting an…](https://mymerci.kr/pages/nclex_q.php?qn_id=396180&lang=en) - [Two days after a femur fracture, a client develops sudden hypoxemia, confusion, and a pete…](https://mymerci.kr/pages/nclex_q.php?qn_id=397278&lang=en) - [A client with a lower-leg fracture in a cast reports rapidly worsening pain despite analge…](https://mymerci.kr/pages/nclex_q.php?qn_id=497750&lang=en) ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=568932&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=568932&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=568932&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=568932&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=568932&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._