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 D

Explanation

A) Have the client swish with commercial mouthwash before therapy:
Some commercial mouthwashes contain alcohol, which can be irritating to the mucous membranes, especially in clients undergoing chemotherapy. Chemotherapy can cause mucositis or stomatitis, making the oral cavity more sensitive, so alcohol-based mouthwashes should be avoided

B) Place fresh flowers in the client's room:
Fresh flowers are not recommended in the rooms of clients undergoing chemotherapy because they can introduce bacteria into the environment, which is particularly concerning for clients with weakened immune systems due to chemotherapy. Chemotherapy suppresses the immune system, increasing the risk of infection.

C) Tell the client to expect dark stools following chemotherapy:
Chemotherapy can cause a variety of gastrointestinal side effects, but dark stools are not a typical or expected side effect. Dark stools may indicate gastrointestinal bleeding, which requires immediate attention.

D) Administer an antiemetic prior to the procedure:
Chemotherapy commonly causes nausea and vomiting, and preemptive administration of antiemetic medications can help prevent these symptoms. The nurse should follow the healthcare provider's orders and administer antiemetics as prescribed, which can significantly improve the client's comfort and adherence to the treatment plan.

A. "Take one tablet every 15 during an acute attack." B. "Take this medication after each meal and at bedtime." C. "Take one tablet at the first indication of chest pain." D. ‘’Take this medication with 8 ounces of water."

Correct Answer is C

Explanation

A) "Take one tablet every 15 minutes during an acute attack."
This is incorrect because the correct instruction is to take one tablet every 5 minutes for up to 3 doses during an acute angina attack, not every 15 minutes. If the chest pain persists after three doses, the client should seek immediate medical attention. Taking a tablet every 15 minutes would delay intervention and could be dangerous in an acute situation.

B) "Take this medication after each meal and at bedtime."
This is not the correct instruction for nitroglycerin use during an angina attack. Nitroglycerin tablets are typically used on an as-needed basis to relieve acute chest pain (angina). They are not intended for routine use after meals or at bedtime. If taken routinely for prevention of angina, the dosing regimen would be different, usually in the form of extended-release formulations.

C) "Take one tablet at the first indication of chest pain."
Nitroglycerin tablets are used to relieve chest pain (angina) by relaxing coronary arteries and improving blood flow to the heart. The client should take one tablet at the first sign of chest pain. If the pain does not resolve within 5 minutes, the client should take a second tablet, and a third if needed, with a total of 3 doses being the maximum before seeking emergency care. This allows for quick relief during an acute angina attack.

D) "Take this medication with 8 ounces of water."
Nitroglycerin tablets should not be taken with water. They are typically absorbed sublingually (under the tongue) and should not be swallowed or taken with water. Taking them with water could delay the absorption process and reduce their effectiveness.

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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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