The head computed tomography (CT) result indicates no bleeding in the brain and the neurologist diagnoses an acute ischemic stroke and orders tPA. Select the appropriate interventions for tPA administration. (Select all that apply)

Choice A reason: Giving an antiemetic treats nausea but doesn’t address the headache and nausea’s cause, likely autonomic dysreflexia in T3 injury. Assessing blood pressure identifies this emergency, making this secondary and incorrect compared to the nurse’s priority of evaluating the patient’s urgent symptoms.

Choice B reason: Checking for fecal impaction is relevant for autonomic dysreflexia but secondary to blood pressure assessment, which confirms the emergency. Immediate BP evaluation is critical, making this delayed and incorrect compared to the nurse’s first action for the patient’s symptoms.

Choice C reason: Assessing blood pressure first is critical, as headache and nausea in a T3 spinal cord injury patient suggest autonomic dysreflexia, a hypertensive emergency. This aligns with neurological nursing priorities, making it the correct initial action to address the patient’s urgent symptoms.

Choice D reason: Notifying the provider is important but follows assessing blood pressure to confirm autonomic dysreflexia. Immediate BP evaluation guides care, making this premature and incorrect compared to the nurse’s first action to evaluate the T3 injury patient’s headache and nausea.

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.