# A client with GBS reports increasing weakness with bedside vital capacity (VC) dropping from 22 to 14 mL/kg over 4 hours. Which interventions should the nurse anticipate? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375096&lang=en  
> language: en  
> subject: Management of Care  
> category: MOC

## Question

A client with GBS reports increasing weakness with bedside vital capacity (VC) dropping from 22 to 14 mL/kg over 4 hours. Which interventions should the nurse anticipate? Select all that apply.

1

Implement DVT prophylaxis with mechanical and pharmacologic measures

2

Monitor for autonomic dysfunction with continuous BP and cardiac monitoring

3

Prepare for elective intubation before respiratory failure becomes emergent

4

Initiate IVIG or plasmapheresis as ordered

5

Use noninvasive ventilation as the definitive airway because of bulbar weakness

## Explanation

Impending neuromuscular respiratory failure in GBS: VC under 15-20 mL/kg, NIF less negative than -25 to -30 cm H2O, single breath count under 20, weakening cough or bulbar dysfunction. ELECTIVE intubation prevents emergent crash airway with aspiration. IVIG (0.4 g/kg/day × 5 days) or plasmapheresis are equivalent disease-modifying therapies; STEROIDS do NOT help. NIV is generally avoided in GBS with bulbar weakness because of aspiration risk and progressive failure — definitive intubation preferred. Autonomic dysautonomia (BP swings, dysrhythmia, ileus) requires continuous monitoring. DVT prophylaxis (SCDs plus heparin) is essential because of immobility.

## In-depth explanation

Memorize 20/30/40: VC under 20, NIF less negative than -30, MIP not adequate, indicates intubation. Weakening single breath count is rapid bedside trend.

## Clinical scenario

NIF -22 cm H2O. Single breath count 12. SpO2 95 percent on room air. Bulbar weakness with weak cough.

## Key concepts

- **vital capacity** — Maximum exhaled volume after deepest inhalation; declines in neuromuscular failure.
- **IVIG** — Intravenous immunoglobulin; first-line GBS therapy alongside plasmapheresis.
- **dysautonomia** — Autonomic instability with BP swings, arrhythmias, GI changes; high mortality in GBS if missed.

## Related questions

- [A nurse is adopting the I-PASS structured handoff tool for end-of-shift report. Which elem…](https://mymerci.kr/pages/nclex_q.php?qn_id=372862&lang=en)
- [The night-shift nurse receives a telephone order from the on-call provider for "morphine 4…](https://mymerci.kr/pages/nclex_q.php?qn_id=373130&lang=en)
- [A nurse is preparing a patient for surgery later today. The provider has just left the roo…](https://mymerci.kr/pages/nclex_q.php?qn_id=373400&lang=en)
- [A 82-year-old presents to clinic with recent falls and worsening confusion. After reviewin…](https://mymerci.kr/pages/nclex_q.php?qn_id=373873&lang=en)
- [A nurse is caring for an agitated post-operative patient who is pulling at the IV and surg…](https://mymerci.kr/pages/nclex_q.php?qn_id=373880&lang=en)
- [Immediately before a bedside lumbar puncture, the nurse leads the team through the Univers…](https://mymerci.kr/pages/nclex_q.php?qn_id=373883&lang=en)
- [A patient with limited English proficiency arrives for discharge teaching with the family.…](https://mymerci.kr/pages/nclex_q.php?qn_id=374874&lang=en)
- [An alert and oriented patient with metastatic cancer states, "I do not want any more chemo…](https://mymerci.kr/pages/nclex_q.php?qn_id=374912&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=375096&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=375096&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=375096&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=375096&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=375096&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._