A nurse is admitting a client who has Guillain-Barre syndrome. The client complains of an inability to move both legs and reports a tingling sensation above the waistline. Which is the most important piece of equipment for the nurse to keep at this client's bedside?

Incentive spirometer

Hoyer lift

Intubation tray

Nebulizer

Answer and Explanation

The Correct Answer is C

A.   This is useful for preventing atelectasis in patients who are unable to take deep breaths, but it is not the most critical piece of equipment for this client at this time.
B.   While a Hoyer lift may be needed for mobility assistance in the future, it is not the most immediate priority.
C.   Guillain-Barre syndrome can rapidly progress, leading to respiratory muscle weakness and the need for mechanical ventilation. Having an intubation tray readily available is crucial to ensure a prompt response if the client's respiratory status deteriorates.
D.   A nebulizer is used to deliver medication to the lungs, but it is not the most critical piece of equipment for this client at this time.

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Correct Answer is C

Explanation

A creatinine level of 1.2 mg/dL is within the upper range of normal but may be slightly elevated depending on the baseline level pre-transplant and individual patient factors. For a client 3 months post- transplant, this level could indicate stable kidney function or a mild increase but is not necessarily indicative of a significant complication.
B.A 24-hour urine output of 1,800 mL is within the normal range for adults (about 1,000 to 2,000 mL per day). This level of urine output suggests that the transplanted kidney is functioning adequately in terms of urine production.
C. An elevated white blood cell count of 13,500/mm³ could indicate an infection or inflammation. This finding is relevant in the context of post-transplant care because patients are at increased risk for infections due to immunosuppressive therapy and the surgical procedure. An elevated WBC count could also suggest an acute rejection episode, as rejection can cause inflammation and an immune response.
D. A BUN level of 18 mg/dL is within the normal range but on the higher end. It might suggest some level of kidney impairment, but it is not necessarily indicative of a severe complication on its own.

A. "The sputum I have been coughing up is pink." B. "I feel short of breath when I lie down flat." C. "The nurse I had yesterday said she could hear fluid in my lungs." D. "Both of my legs are so swollen."

Correct Answer is D

Explanation

A. Pink, frothy sputum is typically associated with left-sided heart failure and pulmonary edema. This occurs when fluid backs up into the lungs due to left-sided heart failure. Since the question pertains to right-sided heart failure, this statement is not consistent with that condition.

B. Feeling short of breath when lying flat is known as orthopnea and is more commonly associated with left-sided heart failure. It occurs due to fluid shifting into the lungs when supine, which aggravates pulmonary congestion. This statement is not consistent with right-sided heart failure.
C. Hearing fluid in the lungs typically indicates left-sided heart failure, where fluid backs up into the pulmonary circulation, causing pulmonary edema. This symptom is associated with left-sided heart failure rather than right-sided heart failure.
D. Swelling of the legs, also known as peripheral edema, is a hallmark of right-sided heart failure. This occurs because the right side of the heart is unable to effectively pump blood out to the lungs, leading to fluid accumulation in the systemic venous circulation and resulting in swelling in the lower extremities and sometimes the abdomen

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A nurse is admitting a client who has Guillain-Barre syndrome. The client complains of an inability to move both legs and reports a tingling sensation above the waistline. Which is the most important piece of equipment for the nurse to keep at this client's bedside?

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Naxlex Comprehensive Predictor Exams

A client who received a kidney transplant 3 months ago is in the nephrologists office for a follow up appointment. Which finding would indicate that the client is experiencing a complication which is common after a kidney transplant?

Correct Answer is C

Explanation

The nurse is performing an admission assessment on a client who is being admitted for right- sided heart failure. Which statement made by the patient would be consistent with right-sided heart failure?

Correct Answer is D

Explanation

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