Patient Data Exhibits The client is ready for transfer to the neurological intensive care unit (ICU). The receiving nurse obtains report from the emergency department (ED) nurse. Received a computed tomography (CT) scan of the head 18 gauge peripheral IV (PIV) in bilateral antecubital spaces CMP, WBC, APTT, PT/INR drawn and results are all WNL 12-Lead ECG normal sinus rhythm (NSR) 0.9% sodium chloride infusing at 50mL/hour Sitting in a semi Fowler's position Client is NPO Pharmacy bringing tissue plasminogen activator (tPA) to the unit shortly Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. During tPA administration, the nurse should prioritize dropdown to monitor for dropdown.

Rationale for Correct Choices: Frequent neurologic assessments: Frequent neurological checks are crucial during and after tPA administration to detect early signs of complications, particularly worsening neurological status, which may indicate intracranial bleeding. These assessments help ensure prompt intervention if deterioration occurs. Intracerebral hemorrhage: Intracerebral hemorrhage is the most serious and well-known risk of thrombolytic therapy. Monitoring for signs such as sudden headache, changes in consciousness, or worsening neurological symptoms is essential to detect this life-threatening complication early. Rationale for Incorrect Choices: Continuous blood pressure monitoring: Although blood pressure control is important during tPA administration, continuous monitoring is not always required. Frequent checks (e.g., every 15 minutes) are typically sufficient unless there is an acute hypertensive crisis or rapid changes in neurological status. Hourly intake and output measuring: While intake and output may be monitored in ICU settings, this is not the priority during tPA administration. It does not help in detecting the most immediate and severe risk associated with thrombolytics. Pulmonary embolism: tPA is used to treat embolic events, not likely to cause them. Pulmonary embolism is not a known complication of thrombolytic therapy in ischemic stroke cases and would not be the primary concern during administration. Deep vein thrombosis: DVT is a potential complication from immobility in stroke patients, but not from tPA use. Monitoring for DVT is important during hospitalization but is not the priority during or immediately after tPA infusion.