a client with a diagnosis of guillain barre syndrome is in a non responsive state yet vital signs are stable and breathing is independent what should
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Nursing Elites

HESI LPN

Fundamentals of Nursing HESI

1. A client with a diagnosis of Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

Correct answer: B

Rationale: The correct answer is B. A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deeper state of unconsciousness than what is described in the scenario. Choice C is inaccurate as the client is not merely sleeping but non-responsive. Choice D is incorrect as a Glasgow Coma Scale of 13 indicates a higher level of consciousness than what is presented in the scenario.

2. When assessing a client's skin as part of a comprehensive physical examination, what finding should a nurse expect?

Correct answer: A

Rationale: The correct answer is A: Capillary refill less than 3 seconds. This finding is considered normal and indicates good peripheral perfusion. Pitting edema (choice B) and pale nail beds (choice C) are abnormal findings that may suggest underlying health issues. Thick skin on the soles of the feet (choice D) is not an expected normal finding during a skin assessment and could be indicative of a callus or other skin condition.

3. A client who is receiving chemotherapy for cancer treatment is experiencing nausea and vomiting. What is the best intervention for the LPN/LVN to implement?

Correct answer: B

Rationale: The best intervention for a client experiencing chemotherapy-induced nausea and vomiting is to provide antiemetic medication as prescribed. This medication helps in managing and reducing nausea and vomiting, providing relief to the client. Offering small, frequent meals (Choice A) may not address the underlying cause of the symptoms. Encouraging clear liquid intake (Choice C) may not be effective in controlling nausea and vomiting associated with chemotherapy. Assisting with oral care (Choice D) is important for overall comfort but may not directly address the symptoms of nausea and vomiting.

4. A client who has had an allogeneic stem cell transplant needs protective measures. What precaution should the nurse plan for this client?

Correct answer: A

Rationale: For a client who has undergone an allogeneic stem cell transplant, it is crucial to minimize exposure to potential sources of infection. Wearing a mask when outside the room, especially in areas with construction or other potential risks, helps protect the client's compromised immune system. Positive pressure airflow rooms are typically used for clients with airborne infections, not for those post-stem cell transplant. Restricting all visitors may contribute to the client's well-being, but it is not a direct protective measure against infection. While HEPA filters can be beneficial in maintaining air quality, wearing a mask when exposed to external risks is a more targeted and immediate protective measure in this scenario.

5. A client requires gastric decompression, and a nurse is inserting an NG tube. Which action should the nurse take to verify proper placement of the tube?

Correct answer: B

Rationale: Measuring the pH of the gastric aspirate is the most reliable method to confirm proper placement of an NG tube. Gastric fluid has an acidic pH, typically ranging from 1 to 5. Assessing the client for a gag reflex (choice A) is important for airway protection but does not confirm tube placement. Placing the NG tube in water to observe for bubbling (choice C) is incorrect and not a reliable method for verifying placement. Auscultating 2.5 cm above the umbilicus while injecting sterile water (choice D) is an outdated method and is not recommended for verifying NG tube placement.

Similar Questions

A healthcare professional is preparing to administer medications to a client. Which of the following client identifiers should the healthcare professional use to ensure medication safety?
A middle adult client tells the nurse, 'I feel so useless now that my children do not need me anymore.' Which of the following responses should the nurse make?
Which statement by the mother indicates that the mother understands safety precautions with her four-month-old infant and her 4-year-old child?
While providing care to a group of patients, which patient should the nurse prioritize seeing first?
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