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The client will be turned every 2 hours is a general nursing care practice for all immobile clients to prevent pressure injuries, but it is not specific to the protocol surrounding the use of restraints.

The client will need to be monitored every one-half hour is incorrect because clients in restraints must be monitored more frequently—typically every 15 minutes, depending on facility policy and client condition, to assess circulation, skin integrity, and psychological well-being.

The physician must be present at the time of the restraint episode is incorrect. While a physician's order is required for restraint use, the physician does not need to be physically present at the time of application. However, the physician must conduct a face-to-face evaluation within a specific timeframe, usually within 1 hour of the restraint being applied, depending on regulatory guidelines.

Inserting an oral airway may be appropriate if the client is biting the endotracheal tube, but in this scenario, the cause of the low-pressure alarm is unknown and could be due to disconnection or a leak — a more urgent issue requiring immediate action.

Suctioning and resetting the alarm could delay appropriate ventilation if the issue is a disconnection or leak; it’s not the priority intervention in an unclear emergency.

Notifying the respiratory therapist and provider is appropriate after immediate interventions are performed to maintain the patient’s airway and oxygenation.

Calling the physician is important if the patient’s condition worsens or if the chest pain persists after the full protocol of nitroglycerin administration (usually up to 3 doses, 5 minutes apart). However, this is not the immediate next action.

Incorrect dosage. The standard dose of sublingual nitroglycerin is 0.4 mg. Giving 4 mg would be a serious overdose and unsafe.

Increasing oxygen might be appropriate if the patient is hypoxic (e.g., low O₂ saturation), but this is not automatically done without assessing vitals first.

Urinary retention can occur in Guillain-Barre Syndrome due to autonomic dysfunction, but it is not the most life-threatening complication.

Hypertension may be seen as part of autonomic instability in GBS, but it is usually not the primary concern.

Hyperglycemia is not a typical complication of GBS itself, unless related to treatments like IV corticosteroids (which are not first-line therapy for GBS) or comorbid conditions.

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Crushing sustained-release tablets is not recommended because doing so could interfere with the controlled release of the medication, which is designed to release slowly over time. This could lead to adverse effects.

Pyridostigmine is typically used regularly, not just as needed. Consistent dosing helps maintain muscle strength and manage the symptoms of MG, rather than only addressing occasional weakness and fatigue.

Doubling the dose without medical advice can be dangerous. The prescribed dose should be followed, and any changes should be discussed with a healthcare provider to avoid potential overdose or side effects.

Levodopa/carbidopa can cause side effects like dyskinesia (unusual movements) or behavioral changes, and these should be reported to the healthcare provider.

Nausea and vomiting are common side effects when starting levodopa/carbidopa, and it's often managed by taking the medication with food or adjusting the dosage.

Levodopa/carbidopa can cause orthostatic hypotension, leading to dizziness or falls. To prevent this, it's important to avoid sudden changes in position and rise slowly from sitting or lying down.