Correct Answer: C

Rationale: After observing the client cough and produce frothy saliva in the collection cup, the nurse should provide the client with a glass of water and mouthwash to rinse the mouth. This action helps clear the mouth of contaminants, ensuring a more accurate sputum specimen for diagnostic testing. Option A is incorrect because suctioning is not the appropriate next step in this situation. Option B is unnecessary as re-instructing the client in coughing techniques may not address the immediate issue of contaminated saliva in the specimen. Option D is premature since labeling and transporting the container should only be done after obtaining a valid specimen.

Correct Answer: C

Rationale: The correct way to apply tape to anchor an eye shield effectively is to attach the tape from the lower eyelid to the upper forehead. This method provides stability for the shield without putting pressure on the eye itself, thus helping to protect the eye.

Choices A, B, and D are incorrect because taping from the cheek to the forehead, securing tape from the nose to the ear, or using circular bandaging around the head may not provide the necessary stability and protection required for the eye shield.

Correct Answer: A

Rationale: The correct answer is to check the client's respiratory rate. Morphine can lead to respiratory depression, which makes it crucial for the nurse to monitor the client's breathing closely. Assessing the respiratory rate helps in early detection of potential respiratory depression and allows prompt intervention. While assessing pain level (choice
B) is important, monitoring the respiratory status takes precedence due to the risk of respiratory depression with morphine. Monitoring blood pressure (choice
C) is relevant but not as crucial as assessing respiratory status in a client receiving morphine. Evaluating the level of consciousness (choice
D) is also important but does not directly address the immediate risk associated with morphine administration.

Correct Answer: D

Rationale: The correct answer is D, prolonged PT/INR. In a client with chronic liver disease, a prolonged PT/INR is the most concerning lab value. This indicates impaired liver function, leading to a higher risk of bleeding. Elevated AST and ALT (choice
A) are indicators of liver damage but do not directly assess the risk of bleeding. Decreased albumin level (choice
B) reflects impaired liver function but is not as directly related to bleeding risk as a prolonged PT/INR. Elevated bilirubin level (choice
C) is a sign of liver dysfunction, specifically related to bile metabolism, and while important, it is not as directly associated with bleeding risk as a prolonged PT/INR in the context of chronic liver disease.

Correct Answer: B

Rationale: In the case of diabetic ketoacidosis, the most critical treatment to initiate is starting an insulin drip. Insulin therapy is crucial for reducing blood glucose levels by promoting glucose uptake in cells and inhibiting the production of ketones. Administering sodium bicarbonate IV is generally not recommended as it may lower the pH further and potentially worsen the condition. While monitoring glucose and ketone levels is important for assessing the response to treatment, initiating insulin therapy takes precedence. Providing oral hydration alone is insufficient to manage the metabolic derangements seen in diabetic ketoacidosis.