Stroke: Time, Thrombolytics and Swallow Screens

Medical-Surgical · Neurology·Updated 2026-10-28

What it is

A stroke is a sudden loss of brain function from interrupted cerebral blood flow, either ischemic (a thrombus or embolus blocks an artery) or hemorrhagic (bleeding into the brain or subarachnoid space). Neurons in the ischemic area die within minutes to hours, so early care is driven by time: establish when the client was last known well, obtain a noncontrast CT to rule out bleeding, and restore flow in eligible ischemic strokes. A left-hemisphere stroke affects language and the right side of the body; a right-hemisphere stroke causes left-sided weakness, neglect and impulsive behavior.

What the NCLEX focuses on

The time last known well starts the treatment clock; a client who wakes with symptoms was last known well before sleep.
Noncontrast CT of the head comes first, to rule out hemorrhage before any thrombolytic; blood glucose is checked because hypoglycemia mimics stroke.
IV alteplase is given within 3 hours of last known well (up to 4.5 hours in eligible clients) once blood pressure is below 185/110 mm Hg.
After alteplase: neurologic checks and blood pressure every 15 minutes for 2 hours, every 30 minutes for 6 hours, then hourly to 24 hours; no anticoagulants or antiplatelets for 24 hours.
Sudden severe headache, nausea and vomiting, rising blood pressure or a drop in consciousness during or after alteplase signals intracranial hemorrhage.
Ischemic stroke without thrombolysis: permissive hypertension; blood pressure is treated only at 220/120 mm Hg or higher.
Dysphagia is common: the client stays NPO, including oral medications, until a bedside swallow screen is passed.

Priority nursing actions

Assess airway, breathing and circulation; give oxygen only to keep SpO2 above 94%.
Establish the time last known well and perform a focused neurologic assessment (NIH Stroke Scale).
Check blood glucose, keep the client NPO and prepare for an immediate noncontrast CT.
Keep blood pressure within the prescribed limits, give alteplase as prescribed, and follow the post-thrombolytic monitoring schedule.
For headache, vomiting or neurologic decline during or after alteplase, stop the infusion and notify the provider at once.

Numbers to know

Value	Target or limit	Why it matters
Alteplase window	Within 3 hours of last known well; up to 4.5 hours in eligible clients	Benefit falls and bleeding risk rises with time
Alteplase dose	0.9 mg/kg (maximum 90 mg): 10% as an IV bolus over 1 minute, the rest over 60 minutes	Weight-based; dosing errors raise bleeding risk
Blood pressure before alteplase	Below 185/110 mm Hg	Higher pressure raises the risk of intracranial hemorrhage
Blood pressure for 24 hours after alteplase	180/105 mm Hg or lower	Reduces hemorrhagic transformation
Ischemic stroke, no thrombolytic	Treat only at 220/120 mm Hg or higher	Permissive hypertension perfuses the ischemic penumbra
Blood glucose	Treat below 60 mg/dL (3.3 mmol/L)	Hypoglycemia mimics stroke deficits

Common exam traps

Choosing sips of water, ice chips or oral medications before the swallow screen: wrong because silent aspiration is common after stroke.
Choosing a rapid-acting antihypertensive for 172/94 mm Hg in ischemic stroke without thrombolysis: wrong because permissive hypertension maintains flow to the penumbra.
Choosing acetaminophen and reassessment for a sudden severe headache after alteplase: wrong because this signals intracranial hemorrhage; stop the infusion and notify the provider.
Choosing to start subcutaneous heparin or aspirin within 24 hours of alteplase: wrong because antithrombotics wait until follow-up imaging excludes bleeding.

What to teach

BE FAST: Balance loss, Eyes (vision loss), Face drooping, Arm weakness, Speech difficulty, Time to call 911; note when symptoms began and never drive to the hospital.
A TIA is a warning: keep follow-up testing, take prescribed antiplatelets, statins and antihypertensives, stop smoking, and take anticoagulants as prescribed for atrial fibrillation.
Homonymous hemianopsia: turn the head toward the blind side to scan the environment.

Client handout: Stroke: Warning Signs and Prevention (nurse guide and printable patient handout).

Try 2 NCLEX-style questions on this topic

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Question 1 · QID 5420D929

Two hours after receiving IV alteplase for ischemic stroke, a client reports a sudden severe headache and becomes drowsy. Which action should the nurse take FIRST?

A. Document the severe headache, obtain repeat vital signs, and reassess neurologic status in 15 to 30 minutes before escalating
B. Explain that headache can occur after ischemic stroke and reduce stimulation while observing for additional neurologic changes
C. Give the prescribed acetaminophen for headache and repeat the neurologic examination at the next scheduled post-alteplase check
D. Stop any remaining infusion and notify the provider immediately: this suggests intracranial hemorrhage

Question 2 · QID A4A54DC7

A client admitted with stroke 3 hours ago asks for water. The swallow screen has not been done. Which action is correct?

A. Keep the client NPO and arrange the bedside swallow screen before any oral intake
B. Offer nectar-thick water by spoon because thicker liquids are generally safer after stroke even before formal screening
C. Offer a few supervised ice chips because the small volume reduces aspiration risk until the swallow screen is completed
D. Give small supervised sips of water while fully upright and stop immediately if coughing or a wet voice develops

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Sources

Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapter: Stroke.
Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. Stroke. 2019;50(12):e344-e418.

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