The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Increased pulse rate, adventitious breath sounds.

Increased pulse rate, respirations of 16 breaths/minute.

Decreased pulse rate, respirations of 20 breaths/minute.

Decreased pulse rate, abdominal breathing.

Answer and Explanation

The Correct Answer is A

Increased pulse rate, adventitious breath sounds. Guillain-Barré syndrome (GBS) is a rare autoimmune disorder that affects the peripheral nervous system. It can cause weakness, paralysis, and difficulty breathing. Increased pulse rate and adventitious breath sounds, such as crackles or wheezes, may indicate that the client is experiencing respiratory distress and needs oral suctioning. Increased pulse rate and respirations of 16 breaths/minute, choice B, may indicate anxiety or pain but are not necessarily indicative of the need for oral suctioning.

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Free Nursing Study Resources

Correct Answer is {"dropdown-group-1":"B"}

Explanation

The term for severe itching is "pruritus," so the nurse should document the client's complaint as such. Pruritus can be caused by a variety of factors, including allergic reactions, skin conditions, and liver or kidney disease.

The nurse should assess the client's skin for any visible signs of irritation or rash and ask about any recent changes in medications or diet. Treatment for pruritus will depend on the underlying cause but may include topical or oral medications, cool compresses, or avoiding irritants.

A. Tissue hypoxia. B. Cardiac failure. C. Hypovolemia. D. Infection.

Correct Answer is C

Explanation

Hypovolemia. Following a serious thermal burn, the nurse takes action to prevent hypovolemia, which can result from fluid loss due to the burn. Hypovolemia can lead to hypoperfusion of vital organs, including the kidneys, and can cause acute renal failure. Preventing hypovolemia is critical to preventing other complications such as tissue hypoxia, cardiac failure, and infection.

A. Tissue hypoxia and cardiac failure are consequences of hypovolemia due to decreased blood flow to organs.

D. Infection is not the immediate complication to prevent but is a potential complication following burn injury.

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The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client comes to the clinic with complaints of severe itching. The nurse documents this as: dropdown

Correct Answer is {"dropdown-group-1":"B"}

Explanation

Following a serious thermal burn, which complication will the nurse take action to prevent first?

Correct Answer is C

Explanation

The nurse is planning care for a client admitted to the neurologic rehabilitation unit following a cerebrovascular accident. Which nursing intervention would be of the highest priority?

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