Stroke and Neurologic Emergencies · NCLEX Exam

What is an essential nursing action post-administration of thrombolytic therapy (tPA) in a patient undergoing acute ischemic stroke?

  1. There is no need to monitor vital signs once tPA is started
  2. Monitor for intracranial hemorrhage and vital signs every 15 minutes
  3. Start therapeutic anticoagulants immediately once tPA is given
  4. Allow the patient unrestricted activity and unrestricted oral intake
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Correct answer: Monitor for intracranial hemorrhage and vital signs every 15 minutes

After tPA administration, the nurse must monitor closely for hemorrhagic conversion, neurologic changes, and vital sign instability.

Difficulty: Medium Question 17 of 20

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