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A client with Guillain-Barré Syndrome (GBS) is admitted to the ICU with progressive weakness and numbness in the limbs. Which priority intervention should the nurse anticipate the healthcare provider will prescribe?

A client is brought to the emergency department after falling down a flight of stairs. Assessment reveals:GCS score: 8 (Eye Opening 3, Verbal Response 3, Motor Response 2)Vital signs: BP 145/90 mm Hg, HR 102 bpm, RR 18/min, SpO₂ 94% on room airThe client is somnolent and responding only to verbal and painful stimuli.Given the client’s GCS of 8, what is the priority nursing intervention?

A client with a severe traumatic brain injury (TBI) is transferred to the ICU. A ventriculostomy catheter has been inserted into the right lateral ventricle to continuously monitor intracranial pressure (ICP) and allow for drainage of cerebrospinal fluid (CSF) as needed.Normal ICP = 5–15 mm Hg. Upon admission to the ICU, the nurse notes that the ventriculostomy drainage system is open to drainage and the ICP monitor reads 25 mm Hg. Which action should the nurse take first?

The nurse is preparing to administer an acetylcholinesterase inhibitor test to a client to rule out myasthenia gravis. Which priority action should the nurse include in the plan of care?

A nurse is caring for a client with pre-renal acute kidney injury (AKI) following major abdominal surgery. The nurse notes the following assessment findings: The client’s urine output over the past 2 hours is 50 mL, blood pressure is 90/58 mmHg, and heart rate is 114 beats per minute with sinus tachycardia. Which provider order should the nurse initiate first?

The nurse is assessing a client with myasthenia gravis. Which symptom is more suggestive of a cholinergic crisis rather than a myasthenic crisis?

A nurse is caring for a client who has sustained a spinal cord injury at the C5 level. Which of the following assessments should the nurse prioritize?

A nurse is assessing a client with end-stage kidney disease (ESKD) who missed their last two hemodialysis sessions. The client has gained 5 kg (11 lb.) in the past week and present with severe dyspnea, crackles in all lung fields, and 3+pitting edema. The morning laboratory results are as followings: potassium: 6.8 mEq/dL, BUN: 90 mg/dL, creatinine: 19.2 mg/dL, pH: 7.20, HCO3 (bicarbonate): 15 mEq/L. Which prescription should the nurse implement first?

A nurse is caring for a client with Guillain-Barré Syndrome (GBS) in the acute care unit. The client has weakness in the lower extremities but is alert and oriented. The nurse is implementing interventions to maximize respiratory function and prevent complications related to immobility. Which nursing intervention should be prioritized?

A client with DKA is receiving IV normal saline and an insulin drip. The nurse notes that the client’s serum potassium is now 2.8 mEq/L, and the client reports muscle weakness and palpitations. Which action should the nurse take first?