Correct Answer: C

Rationale: An oxygen saturation of 90% is below the expected reference range and could indicate respiratory depression, a serious side effect of morphine. This finding requires immediate attention as it may lead to hypoxia. Nausea (choice
A) is a common side effect of morphine but does not pose an immediate threat. A urinary output of 20 mL/hr (choice
B) may indicate decreased renal perfusion but is not as critical as respiratory compromise. A respiratory rate of 14/min (choice
D) is within the normal range and does not suggest immediate danger.

Correct Answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote independence. This approach helps the client regain confidence and autonomy in performing self-care activities. Instructing the client to rest until fully recovered (
Choice
A) may lead to decreased muscle strength and independence. Assigning assistive personnel (
Choice
C) does not empower the client to actively participate in their care. Involving the client's family (
Choice
D) may provide support but does not directly encourage the client's independence.

Correct Answer: B

Rationale: The correct first action for a client with an NG tube experiencing nausea and decreased gastric secretions is to irrigate the NG tube with sterile water. This can help clear any blockages in the tube, which may be causing the symptoms. Positioning the client on their left side may be helpful for enteral feedings but is not the priority in this situation. Replacing the NG tube should not be the initial step unless irrigation fails to resolve the issue. Increasing the suction setting without attempting to clear the blockage can be harmful to the client.

Correct Answer: D

Rationale: The correct intervention when a client develops redness and warmth at the IV site, indicating phlebitis, is to discontinue the IV and notify the provider. This is crucial to prevent further complications. Elevating the IV site and applying an ice pack (
Choice
A) may not address the underlying issue of phlebitis. Administering an anti-inflammatory medication (
Choice
B) is not the primary intervention for phlebitis. Applying a cold compress (
Choice
C) may provide temporary relief but does not address the need to discontinue the IV when phlebitis occurs.

Correct Answer: B

Rationale: The correct answer is to instruct the client not to get out of bed. Lorazepam is a sedative that can cause drowsiness and impair coordination. By instructing the client not to get out of bed, the nurse helps prevent falls or injuries that could occur due to the medication's sedative effects.
Choice A is incorrect as keeping the client awake may not be necessary and could lead to unnecessary discomfort.
Choice C is incorrect as encouraging the client to drink fluids is not directly related to the administration of lorazepam.
Choice D is incorrect as early ambulation is not safe immediately after administering a sedative medication.