Correct Answer: B

Rationale: Instructing the client to take the medication at bedtime is the most appropriate intervention. Taking antipsychotic medications at bedtime can help reduce the impact of sedation on the client's daily activities. This approach allows the client to sleep through the sedative effects.
Choice A is incorrect because just reassuring the client may not address the immediate issue of sedation.
Choice C is incorrect as taking the medication with food does not directly address the sedation concern.
Choice D is not the first-line intervention; adjusting the dosage should be done by the healthcare provider after assessing the client's response to the medication.

Correct Answer: B

Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a critical condition requiring immediate intervention to improve oxygenation. Hypoxemia can lead to tissue hypoxia and further complications. A productive cough with yellow sputum is common in pneumonia but may not require immediate intervention unless it worsens or is associated with other concerning symptoms. A respiratory rate of 20 breaths per minute is within the normal range, indicating adequate ventilation. A heart rate of 90 beats per minute is also within a normal range and may not require immediate intervention unless it is accompanied by other abnormal findings.

Correct Answer: D

Rationale: In this scenario, the patient's periorbital bruising and bloody drainage from both ears suggest a severe head injury. Projectile vomiting is a red flag symptom that may indicate increased intracranial pressure, which requires immediate attention to prevent further neurological deterioration. Rebound abdominal tenderness (choice
A) typically indicates peritonitis and is not directly related to the primary head injury. Diminished breath sounds bilaterally (choice
B) suggest a pneumothorax or hemothorax, which are important but not as immediately life-threatening in this context. Rib pain with deep inspiration (choice
C) is concerning for rib fractures or pulmonary contusion, which are also important but do not take precedence over addressing the potential increased intracranial pressure.

Correct Answer: C

Rationale:
Correct Answer: Monitoring for signs of infection, such as fever or sore throat, is crucial when a client with rheumatoid arthritis is prescribed disease-modifying antirheumatic drugs (DMARDs). DMARDs can suppress the immune system, making individuals more susceptible to infections. Early detection of infections allows for prompt treatment and helps prevent complications.

Choices A, B, and D are incorrect because while liver toxicity and gastrointestinal side effects are possible side effects of DMARDs, monitoring for signs of infection takes priority due to the increased risk of infections associated with these medications.

Correct Answer: D

Rationale: In a client with chronic liver disease developing jaundice, the most important assessment the nurse should perform is to monitor the client's urine output closely. Jaundice can indicate worsening liver function, so monitoring urine output helps assess kidney function and fluid balance, which are critical in chronic liver disease. Assessing the client's skin for lesions or sores (
Choice
A) may be relevant for dermatological conditions but is not the priority in this case. Monitoring liver function tests (
Choice
B) is important but may not provide immediate information on the client's current status. Assessing for changes in mental status and behavior (
Choice
C) is important for detecting hepatic encephalopathy but does not directly address the immediate concern of fluid balance and kidney function in the presence of jaundice.