SCRN Hyperacute Care 2 — Questions and Answers
Question 1: A patient arrives with acute ischemic stroke symptoms. Which blood pressure target is recommended BEFORE IV tPA administration if BP is elevated?
- Below 185/110 mmHg (Correct answer)
- Below 160/90 mmHg
- Below 200/120 mmHg
- Below 140/80 mmHg
Correct answer: Below 185/110 mmHg
Blood pressure must be below 185/110 mmHg before IV tPA can be safely administered to reduce hemorrhagic transformation risk.
Question 2: Which medication is the preferred first-line agent to rapidly lower blood pressure prior to tPA eligibility in acute ischemic stroke?
- Labetalol IV or nicardipine IV (Correct answer)
- Hydralazine PO
- Nitroprusside infusion
- Metoprolol PO
Correct answer: Labetalol IV or nicardipine IV
Labetalol IV boluses or nicardipine infusion are first-line agents for rapid, controlled BP reduction before tPA in acute ischemic stroke.
Question 3: In hyperacute stroke care, what does a NIHSS score of 0 indicate?
- No stroke deficits detected (Correct answer)
- Patient is comatose
- Maximum stroke severity
- Hemorrhagic conversion
Correct answer: No stroke deficits detected
An NIHSS score of 0 indicates no neurological deficits on the scale's 42-point range from 0 (normal) to 42 (most severe).
Question 4: During hyperacute stroke, a patient's oxygen saturation drops to 93%. What is the nurse's priority intervention?
- Apply supplemental oxygen to maintain SpO2 ≥94% (Correct answer)
- Prepare for immediate intubation
- Administer IV dexamethasone
- Elevate head of bed to 90 degrees
Correct answer: Apply supplemental oxygen to maintain SpO2 ≥94%
Supplemental oxygen should be provided to maintain SpO2 ≥94%, as hypoxia worsens ischemic brain injury.
Question 5: A patient with acute stroke is NPO pending swallow evaluation. Which IV fluid is contraindicated due to risk of cerebral edema?
- Hypotonic fluids (e.g., 0.45% NaCl) (Correct answer)
- Normal saline (0.9% NaCl)
- Lactated Ringer's solution
- Hypertonic saline (3% NaCl)
Correct answer: Hypotonic fluids (e.g., 0.45% NaCl)
Hypotonic fluids are contraindicated in stroke because they can worsen cerebral edema by promoting fluid shift into brain tissue.
Question 6: What is the maximum recommended door-to-needle time for IV tPA in acute ischemic stroke per AHA/ASA guidelines?
- 60 minutes (Correct answer)
- 30 minutes
- 90 minutes
- 120 minutes
Correct answer: 60 minutes
The AHA/ASA recommends a door-to-needle time of 60 minutes or less for IV tPA to optimize outcomes in acute ischemic stroke.
Question 7: A patient receiving IV tPA suddenly develops severe headache and hypertension. What is the nurse's immediate priority action?
- Stop the tPA infusion and notify the physician immediately (Correct answer)
- Slow the infusion rate and reassess in 15 minutes
- Administer analgesics and continue monitoring
- Increase the infusion rate to complete the dose faster
Correct answer: Stop the tPA infusion and notify the physician immediately
Sudden severe headache and hypertension during tPA infusion are warning signs of symptomatic intracranial hemorrhage requiring immediate cessation of tPA.
SCRN Hyperacute Care 2
A patient arrives with acute ischemic stroke symptoms.
Which blood pressure target is recommended BEFORE IV tPA administration if BP is elevated?