The nurse working in the Neuro ICU is caring for a client with Guillain Barre Syndrome. Which of the following activities would be best assigned to the Licensed practical nurse (LPN)?

Begin initial discharge teaching on home care activities

Begin administration of red blood cells

Reassess the clients mobility in the upper extremity

Administration of morphine for pain

Answer and Explanation

The Correct Answer is D

A) Begin initial discharge teaching on home care activities:
While discharge teaching is a vital part of the care process, it is typically an activity assigned to a registered nurse (RN) because it involves comprehensive patient education on topics such as medication management, follow-up care, and recognizing signs of complications. Guillain-Barré syndrome (GBS) often requires intensive care in the acute phase, and the RN is responsible for evaluating the client’s readiness for discharge and ensuring they fully understand the care required at home

B) Begin administration of red blood cells:
Administering blood products, such as red blood cells, requires close monitoring for potential reactions, and it is typically the responsibility of the RN. The RN must assess the client’s baseline status, monitor for transfusion reactions, and adjust care accordingly during the procedure. This task requires a higher level of clinical judgment and nursing knowledge than an LPN.

C) Reassess the client's mobility in the upper extremity:
Reassessing a client’s mobility, especially in a neurological condition like Guillain-Barré syndrome, requires detailed and ongoing assessment to determine changes in the patient’s strength, motor function, and overall neurological status. This activity is a more complex task that requires a registered nurse's clinical expertise.

D) Administration of morphine for pain:
The administration of pain medications, including morphine, can be appropriately assigned to the LPN under the supervision of an RN. The LPN is trained to administer medications and monitor for common side effects such as respiratory depression, especially in clients who may be at risk due to their neurological condition. However, it is essential for the LPN to communicate with the RN and report any significant changes in the client’s condition during pain management.

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Correct Answer is A

Explanation

A) Crackles upon auscultation:
Left-sided heart failure occurs when the left ventricle is unable to effectively pump blood to the body, causing blood to back up into the lungs. This results in pulmonary congestion, which often manifests as crackles (also called rales) upon auscultation, particularly in the lower lobes of the lungs. The crackles are caused by the fluid accumulation in the alveoli, a hallmark sign of left-sided heart failure.

B) Palpable liver during assessment:
A palpable liver is more commonly associated with right-sided heart failure. In right-sided heart failure, the blood backs up into the venous system, causing congestion in organs such as the liver and spleen. This leads to hepatomegaly (enlargement of the liver), which can be palpated during physical examination. Therefore, a palpable liver is not typically a manifestation of left-sided heart failure.

C) Pitting Edema:
Pitting edema is more characteristic of right-sided heart failure. When the right ventricle is unable to pump blood effectively, blood backs up in the systemic circulation, leading to fluid retention and edema in the lower extremities, abdomen (ascites), or other dependent areas. While pitting edema can occur in left-sided heart failure, it is more commonly a finding in right-sided heart failure or congestive heart failure.

D) Distended jugular veins:
Distended jugular veins (JVD) are also a sign of right-sided heart failure, not left-sided heart failure. When the right side of the heart fails, blood backs up in the venous system, leading to increased venous pressure, which can be observed as jugular venous distension. This is a key finding in right-sided heart failure.

A. Peaked T waves B. Inverted P waves C. Widened QRS D. Prominent U wave

Correct Answer is A

Explanation

A) Peaked T waves:
Peaked T waves are a classic sign of hyperkalemia on an EKG. As potassium levels rise, the T waves become taller, more pointed, and narrow, indicating changes in the heart's electrical conduction. This is one of the earliest and most characteristic EKG changes seen with hyperkalemia. Hyperkalemia can result from conditions such as kidney dysfunction, use of potassium-sparing diuretics, or other electrolyte imbalances.

B) Inverted P waves:
Inverted P waves typically suggest issues such as atrial ischemia or ectopic atrial rhythms but are not a hallmark sign of hyperkalemia. They may also appear with other conditions, like atrial fibrillation or atrial flutter. However, inverted P waves are not typically linked to elevated potassium levels.

C) Widened QRS:
A widened QRS complex can occur in several conditions, including hyperkalemia, but it is generally seen in more severe cases. As potassium levels rise further, the QRS complex may widen due to delayed conduction through the ventricles. Although a widened QRS can indicate hyperkalemia, it is a later sign, and it typically occurs after more specific changes like peaked T waves.

D) Prominent U wave:
Prominent U waves are more often associated with hypokalemia (low potassium levels) rather than hyperkalemia. U waves are typically seen after the T wave on the EKG and can be more prominent in conditions of low potassium.

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The nurse working in the Neuro ICU is caring for a client with Guillain Barre Syndrome. Which of the following activities would be best assigned to the Licensed practical nurse (LPN)?

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