A patient from the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available? (Select all that apply)

Choice A reason: Screening for recent GI bleeding is critical, as tPA increases bleeding risk, contraindicating its use in such patients. This aligns with stroke treatment protocols, making it a correct intervention the nurse must ensure before administering tPA for acute ischemic stroke.

Choice B reason: tPA is effective within 4.5 hours of stroke onset, not 8 hours, for most patients. This is incorrect, as it exceeds the therapeutic window, unlike screening for bleeding or monitoring, which are essential interventions for safe tPA administration in stroke care.

Choice C reason: tPA, a high-risk thrombolytic, requires two-nurse verification to ensure accurate dosing and administration, reducing errors. This aligns with medication safety protocols, making it a correct intervention the nurse must follow when administering tPA for an acute ischemic stroke.

Choice D reason: Embolic strokes are candidates for tPA if within the time window and no contraindications exist. This is incorrect, as it wrongly excludes a valid stroke type, unlike monitoring or bleeding screening, which are critical for safe tPA administration.

Choice E reason: Close monitoring of vital signs and neurologic status is essential post-tPA to detect complications like hemorrhage or worsening stroke. This aligns with stroke care guidelines, making it a correct intervention the nurse must implement during tPA administration for ischemic stroke.

Choice A reason: A bowel program prevents fecal impaction, a common trigger of autonomic dysreflexia in T4 paraplegia patients. This aligns with spinal cord injury care protocols, making it the correct nursing action to include in the home health plan to prevent this hypertensive emergency.

Choice B reason: A high-protein diet supports nutrition but doesn’t directly prevent autonomic dysreflexia, triggered by stimuli like impaction. A bowel program is more relevant, making this incorrect, as it doesn’t address the primary cause of dysreflexia in the patient’s care plan.

Choice C reason: Quad coughing aids respiratory function but is unrelated to preventing autonomic dysreflexia, caused by visceral stimuli. A bowel program targets this risk, making this incorrect, as it doesn’t address the triggers of dysreflexia in the T4 paraplegia patient’s plan.

Choice D reason: Discussing sexuality and fertility supports quality of life but doesn’t prevent autonomic dysreflexia, linked to physical triggers. A bowel program is preventive, making this incorrect, as it’s unrelated to the physiological causes of dysreflexia in the home health care plan.