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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Correct Answer is ["A","B","D","E"]

Explanation

When performing pin care, the nurse should use aseptic technique and obtain a culture if purulent drainage is present. The applicator should be used only once, and the site should be cleaned, working toward the pin. Crusts around the pin site should not be removed as this can cause trauma to the site and increase the risk of infection.

Choice C, Gently remove crusts around pin sites is not appropriate as this can cause trauma to the site and increase the risk of infection.

A. Impaired Mobility. B. Impaired Gas Exchange. C. Self-Care Deficit. D. Diarrhea.

Correct Answer is B

Explanation

Impaired Gas Exchange. Impaired gas exchange is the greatest concern in the immediate postoperative period for a client recovering from bariatric surgery, as the client may have difficulty breathing due to anesthesia, pain medication, or obesity-related respiratory problems.

Option A, Impaired Mobility, is a concern but not the greatest concern in the immediate postoperative period.

Option C, Self-Care Deficit, may be an issue but is not the greatest concern in the immediate postoperative period.

Option D, Diarrhea, may occur after bariatric surgery but is not the greatest concern in the immediate postoperative period.

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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

When performing pin care, which of the following would be most appropriate? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

A client, who is recovering from bariatric surgery, is returning from the post-anesthesia care unit. Which nursing assessment is of greatest concern in the immediate postoperative period for this client?

Correct Answer is B

Explanation

During a pharmacology class, the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

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