Stroke Savvy
True or False: All stroke patients should be placed on telemetry monitoring
True — telemetry helps detect new-onset atrial fibrillation, a common cause of embolic strokes.
After giving a PRN IV antihypertensive, like hydralazine or labetalol, what critical nursing intervention must be done?
Recheck the blood pressure and HR to evaluate the effectiveness of the medication and monitor for hypotension, every 10 minutes x 2.
True or False: If you don’t have an order label for a specimen, you can send the specimen with just an order requisition form.
False – All specimens must be labeled with a patient-specific label (such as an order label or patient ADT label). Sending an unlabeled specimen, even with a requisition, is a serious safety violation and will be rejected by the lab.
Name three modifiable risk factors for stroke that should be included in patient education.
Hypertension
Smoking
Diabetes
High cholesterol
Physical inactivity
Obesity
Excessive alcohol use
Atrial fibrillation (if unmanaged)*
This class of medications should be used cautiously or avoided in geriatric patients as they can worsen delirium and cognitive function.
What are benzodiazepines?
Name three fall prevention strategies nurses should implement for high-risk patients.
A: 1. Bed/chair alarm activated
2. Call light within reach
3. Q2 rounding
4. Non-slip footwear
5. Lower bed position
6. Toileting schedule
7. yellow fall risk bracelet
8. AM and PM daily safety huddle
9. fall prevention signs
To meet Joint Commission stroke certification standards, patients must receive discharge education on these five key topics
What is:
- Written discharge instructions,
- Activation of EMS,
- Follow-up plan after discharge
- Medications prescribed at discharge
- Warning signs and symptoms of stroke
When administering 3% hypertonic saline how often should you typically monitor serum sodium levels?
Every 4 to 6 hours (frequency depends on the patient’s condition and hospital protocol) to avoid rapid sodium shifts.
You are caring for a patient with a chest tube.
How do you ensure that the correct nursing interventions are being followed?
Use Ellucid- it is filled with policies/procedures and guidelines that are evidenced based in determining nursing practice.
When should the nursing swallow screen be done and how is it documented?
Swallow screen must be done and documented before administering any oral intake, including medications, and must include pass/fail result.
If the patient fails, notify provider to request SLP evaluation and maintain strict NPO.
Your patient is being discharged s/p a craniotomy and will be going home on dexamethasone. What key education do you provide?
Importance of following the taper, not stopping abruptly. Reach out to team if sx return or progress.
True or False: There is no need to call a rapid response if the doctor is already at the patient’s bedside.
What is False?
Explanation:
Nurses are empowered to call a rapid response anytime they feel concerned about a patient’s condition — even if the doctor is present.
The rapid response policy supports both patient safety and the nurse, providing additional expertise and resources quickly. Calling a rapid is about advocating for the patient and ensuring timely intervention, not about waiting for physician permission.
This term describes the prevention of dangerous blood clots in stroke patients using medications or devices.
Answer:
What is VTE (venous thromboembolism) prophylaxis?
Your patient is ordered for a heparin nomogram and is due to be titrated. The PTT has resulted, what two things should be confirmed prior to taking action?
1. Date and time the lab was drawn
2. Result value (is it in therapeutic range?)
You are caring for an EBB patient on 5D who is off meds and awaiting an event. Name three safety interventions to have in place.
1. Suction set up in room
2. IV patent
3. 02 set up in room
4. Rescue meds ordered
5. Seizure pads
6. Can always initiate a RR d/t limited resources on 5D