The healthcare provider is caring for a client with Guillain-Barr© syndrome. Which assessment finding requires the healthcare provider's immediate action?

Correct Answer: D

Rationale: The correct answer is D: Decreased vital capacity. This finding indicates respiratory muscle weakness, which can lead to respiratory failure in Guillain-Barr© syndrome. Immediate action is needed to prevent respiratory compromise. Choice A is a common finding in Guillain-Barr© and does not require immediate action. Choice B is characteristic of Guillain-Barr© and should be monitored but not the most urgent. Choice C could indicate other issues but is not as critical as respiratory compromise.

Correct Answer: A

Rationale: The correct answer is A: Blood urea nitrogen (BUN). BUN is a waste product that reflects protein intake and kidney function. In chronic kidney disease, high protein intake can increase BUN levels, so monitoring BUN helps assess the effectiveness of the low-protein diet. Incorrect choices: B: Serum potassium - This is more related to kidney function but not specifically affected by a low-protein diet. C: Serum calcium - Calcium levels are not directly affected by protein intake or a low-protein diet in chronic kidney disease. D: Creatinine clearance - This measures kidney function but is not directly influenced by protein intake.

Correct Answer: B

Rationale: The correct answer is B: Take the medication with meals. Metformin is typically taken with meals to minimize gastrointestinal side effects. Food helps in the absorption and tolerance of the medication. Taking it on an empty stomach can lead to stomach upset. Taking it at bedtime may also cause nighttime disruptions. Taking it as needed for high blood sugar is not appropriate as metformin is usually taken regularly to control blood sugar levels.

Correct Answer: B

Rationale: The correct answer is B: Prothrombin time (PT) and international normalized ratio (INR). Warfarin works by inhibiting vitamin K-dependent clotting factors, affecting the PT and INR. Monitoring these levels helps assess the effectiveness of warfarin in preventing clot formation. Platelet count (A) assesses clotting ability but not the effectiveness of warfarin. Activated partial thromboplastin time (C) assesses intrinsic pathway clotting factors, not affected by warfarin. Fibrinogen level (D) assesses the final step of clot formation, not specific to warfarin effectiveness.

Correct Answer: C

Rationale: Correct Answer: C - Keep the head of the bed elevated at 30 degrees. Rationale: 1. Elevating the head of the bed at 30 degrees helps prevent aspiration by promoting proper drainage of gastric contents. 2. This position reduces the risk of reflux and pulmonary complications in clients with NG tubes. 3. It also helps maintain the proper position of the tube in the stomach, decreasing the likelihood of displacement. Summary of Other Choices: A. Flushing the NG tube with water before and after feedings is important for tube patency but does not directly prevent complications associated with the NG tube. B. Checking gastric residual volume every 6 hours is important to monitor feeding tolerance but does not directly prevent complications related to the NG tube. D. Replacing the NG tube every 24 hours is not necessary unless there are specific indications such as tube blockage or dislodgment. Regular replacement can increase the risk of complications and is not a standard practice.