Tissue Plasminogen Activator (t-PA) is to be administered to a patient in the trauma and emergency unit with a stroke. Which of the following is a priority action?

1. A

   Check serum electrolytes sodium and potassium

2. B

   Check the apical pulse rate of the patient

3. C

   Check blood grouping and cross-matching

4. D

   Check for any signs of bleeding

Appeared in: DSSSB 12 August 2024

Explanation

• Tissue Plasminogen Activator (t-PA) is a powerful thrombolytic ('clot-busting') medication used to dissolve the clot causing an ischemic stroke.
• The primary and most dangerous side effect of t-PA is bleeding, as it interferes with the body's normal clotting process.
• The most life-threatening form of bleeding is intracranial hemorrhage, which can lead to increased intracranial pressure, further brain damage, and death.
• Therefore, the highest priority nursing action is to continuously and vigilantly monitor the patient for any signs of bleeding, both internal (e.g., headache, change in consciousness) and external (e.g., oozing from IV sites, blood in urine).

Why Other Options Were Wrong

• Option A: Checking serum electrolytes is a component of general patient care and is important for overall stability, but it does not address the specific, immediate, and life-threatening complication of hemorrhage associated with t-PA.
• Option B: Monitoring the apical pulse is part of routine vital sign assessment. While tachycardia can be a sign of hypovolemic shock from severe bleeding, it is often a later sign. Direct assessment for bleeding is a more immediate and primary action.
• Option C: This is a preparatory action, not a monitoring action. It is done in anticipation of a potential need for a blood transfusion if severe bleeding occurs. The immediate priority is to detect the bleeding in the first place.

Related Visual

Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Nursing priorities and complication management during thrombolytic (t-PA) therapy for ischemic stroke in acute care settings.
• Nurses are central to the safe administration of t-PA, which includes performing frequent neurological assessments (e.g., using the NIHSS scale) and vital sign checks (every 15 minutes for the first 2 hours).
• Strict bleeding precautions are a key nursing responsibility. This includes avoiding intramuscular injections, minimizing venipunctures, and delaying the placement of urinary catheters or nasogastric tubes.
• Patient safety depends on the nurse's ability to rapidly identify signs of hemorrhage and immediately report them to the physician or stroke team.

How to Approach the Question

• First, identify the key element in the question: the drug being administered is Tissue Plasminogen Activator (t-PA).
• Recall the drug's classification and primary action. t-PA is a thrombolytic, meaning it dissolves blood clots.
• Consider the most significant and life-threatening side effect associated with this action. For any medication that breaks down clots, the primary risk is bleeding (hemorrhage).
• Analyze the options to determine which one directly addresses this primary, life-threatening risk.
• The action of 'checking for any signs of bleeding' is the only option that directly involves monitoring for the most critical complication of t-PA therapy.
• Eliminate the other options as they represent routine care (electrolytes, pulse) or preparatory measures (blood typing), which are of lower priority than monitoring for an active, life-threatening side effect.

Concept Tested & Keywords

• Concept Tested: Nursing priorities and complication management during thrombolytic (t-PA) therapy for ischemic stroke.
• Stem keywords: Tissue Plasminogen Activator (t-PA), stroke, trauma and emergency unit, priority action
• Lead-in keywords: priority action
• Clinical cues: The care setting changes urgency, monitoring level, and the expected nursing action.
• Negative lead-in flag: false

Question ID

QcVdAbtZ9kN38K3Io-k4-9

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 p. 64-66