Correct Answer: C

Rationale: Pink frothy sputum is a sign of pulmonary edema, which needs immediate intervention to prevent respiratory failure.

Correct Answer: C

Rationale: The nurse should first gather more details to better understand the situation before proceeding with documentation or reporting.

Correct Answer: D

Rationale: A pulse oximetry reading of 88% indicates hypoxemia, which requires immediate intervention to improve oxygenation. The use of accessory muscles and a barrel chest appearance are common in COPD but do not require urgent intervention.

Correct Answer: A

Rationale: A serum creatinine level of 2.0 mg/dL indicates possible acute kidney injury, which can occur during severe systemic inflammatory response syndrome (SIRS). Reporting this value promptly allows for interventions to prevent further renal damage.

Correct Answer: B

Rationale: Diminished breath sounds in a sedated client with ARDS and on a ventilator indicate collapsed alveoli, which requires immediate intervention, such as chest tube insertion, to prevent further lung damage.