SCRN Hyperacute Care 2

Question 1

A patient arrives with acute ischemic stroke symptoms. Which blood pressure target is recommended BEFORE IV tPA administration if BP is elevated?

Accepted Answer

Below 185/110 mmHg

Answer

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?

Accepted Answer

Labetalol IV or nicardipine IV

Answer

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?

Accepted Answer

No stroke deficits detected

Answer

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?

Accepted Answer

Apply supplemental oxygen to maintain SpO2 ≥94%

Answer

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?

Accepted Answer

Hypotonic fluids (e.g., 0.45% NaCl)

Answer

Hypotonic fluids are contraindicated in stroke because they can worsen cerebral edema by promoting fluid shift into brain tissue.

(SCRN) Stroke Certified Registered Nurse Practice Test