The practical nurse (PN) is assessing an older client with left-sided heart failure (HF). What intervention is most important for the PN to implement?

While caring for a client with Guillain-Barre syndrome, the practical nurse (PN) should report the finding of irregular heart rate to the charge nurse. Guillain-Barre syndrome is a neurological disorder that can affect multiple body systems, including the autonomic nervous system.

Autonomic dysfunction can lead to various cardiovascular abnormalities, such as changes in heart rate and rhythm.

However, irregular heart rate can indicate potential cardiac involvement or autonomic instability, which requires prompt evaluation and intervention. Therefore, the PN should report the finding of an irregular heart rate to the charge nurse for further assessment and appropriate management.

Incorrect:

A, B- Full facial flushing and profuse diaphoresis are common symptoms that can occur in Guillain-Barre syndrome due to autonomic dysfunction. While these findings should be noted and monitored, they may not require immediate reporting unless they are severe or accompanied by other concerning symptoms.

C- Lower leg weakness is a characteristic symptom of Guillain-Barre syndrome and is expected in this condition. The PN should document and monitor the extent and progression of weakness but does not necessarily need to report it unless there are significant changes or complications.

Inspecting the client's skin near the end of the bathing procedure allows the PN to directly assess the UAP's performance and evaluate the effectiveness of the bed bath. By observing the client's skin, the PN can determine if the UAP has properly cleaned and cared for the client's skin, identified any areas that may have been missed, and ensured that proper hygiene practices have been followed.
B. While verifying with the client that the bath was complete and thorough is important for client satisfaction, it may not provide a comprehensive evaluation of the UAP's performance. Clients may not be aware of all the necessary steps involved in a complete bed bath, so their perception may not accurately reflect the quality of the UAP's work.
C. Requesting the UAP to report and chart when the bath is complete is a useful documentation practice, but it does not provide a direct evaluation of the UAP's performance during the bed bath.
D. Asking another UAP to help the orientee may be helpful for providing guidance and support during the orientation process, but it does not provide a specific evaluation of the UAP's performance in completing the bed bath.