Following the use of a thrombolytic agent in the management of cerebrovascular accident (CVA) client, which is the priority nursing assessment?
A) Pulse
B) Respirations
C) Airway
D) Blood pressure
D
Feedback:
The use of tissue plasminogen activator (TPA), a thrombolytic agent, has been found to limit the neurologic deficits when given within 3 hours after onset of an ischemic CVA. Blood pressure is a critical assessment factor during the first 24 hours to determine intracerebral hemorrhage, which is a major complication associated with thrombolytic use. Airway is always a priority but not significant with thrombolytic use. Pulse and respirations can also indicate signs of hypovolemic shock resulting from hemorrhage.
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