Correct Answer: C

Rationale: Elevated blood pressure (140/90 mmHg) is a significant finding that the nurse should report immediately. Hypertension can be a severe side effect of corticosteroid therapy, especially in clients with preexisting conditions like rheumatoid arthritis. It requires prompt intervention to prevent complications such as cardiovascular events. The other options, while important to monitor, are not as critical as elevated blood pressure in this context. A blood glucose level of 180 mg/dL may indicate hyperglycemia, weight gain could be due to fluid retention, and increased joint pain is expected in a client with severe rheumatoid arthritis.

Correct Answer: A

Rationale: The correct answer is to transfuse packed red blood cells first. The client's low hemoglobin level of 7 g/dL indicates severe anemia, which requires immediate transfusion to increase oxygen-carrying capacity. While obtaining blood and sputum cultures (
Choice
B) is important to identify potential infections, addressing the critical issue of anemia takes precedence. Infusing normal saline (
Choice
C) may help with volume status but does not address the primary concern of low hemoglobin. Titration of oxygen (
Choice
D) is crucial, but transfusion to improve oxygen-carrying capacity should be the priority in this scenario.

Correct Answer: A

Rationale: The correct answer is A: Hypernatremia. In a client with Diabetes Insipidus, hypernatremia, an elevated sodium level in the blood, can lead to neurological symptoms such as confusion, seizures, or coma. Immediate intervention is necessary to prevent these serious complications. Excessive thirst (choice
B) is a common symptom of Diabetes Insipidus but does not require immediate intervention. Elevated heart rate (choice
C) and poor skin turgor (choice
D) are important assessments but are not as critical as hypernatremia in this context.

Correct Answer: D

Rationale: The 82-year-old client with Alzheimer's disease and a newly fractured femur should receive the most care hours by a registered nurse because they are at the highest risk for injury and complications. The client's age, diagnosis of Alzheimer's disease, and the presence of a newly fractured femur along with the Foley catheter and wrist restraints indicate a need for close monitoring and care.
Choice A is less critical as the client is stable post-appendectomy.
Choice B, though experiencing symptoms, is not at the same level of risk as the client in
Choice D.
Choice C, while requiring oxygen support, does not have the same level of acuity and complexity as the client in
Choice D.

Correct Answer: A

Rationale: A serum potassium level of 3.0 mEq/L is most concerning in a client receiving furosemide as it indicates hypokalemia, which requires immediate intervention. Hypokalemia can lead to serious cardiac arrhythmias, which can be life-threatening. Serum sodium of 135 mEq/L and serum creatinine of 1.8 mg/dL are within normal ranges and do not require immediate intervention in this case. Blood glucose of 200 mg/dL is elevated but does not pose an immediate threat to the client's life in the context of heart failure and furosemide therapy.