Stroke and Neurologic Emergencies · NCLEX Exam

For an ischemic stroke patient eligible for thrombolysis, what is a key early nursing intervention?

  1. Elevate head of bed to 45 degrees and defer all vital sign monitoring until stable
  2. Maintain airway, give oxygen if hypoxic, monitor neuro status every 15 minutes
  3. Start full-dose anticoagulants immediately without a physician order
  4. Allow unrestricted oral intake before a swallow screen is performed
Show answer and explanation

Correct answer: Maintain airway, give oxygen if hypoxic, monitor neuro status every 15 minutes

Early care includes airway/oxygen support and frequent neuro and vital sign monitoring for quick recognition and stabilization.

Difficulty: Medium Question 3 of 20

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