Correct Answer: B

Rationale: The correct intervention for a client with acute diverticulitis is to initiate a low-fiber diet. A low-fiber diet helps manage acute diverticulitis by reducing irritation to the colon, allowing it to heal. Administering a cleansing enema (Choice A) can worsen diverticulitis by increasing pressure within the colon. Applying moist heat to the abdomen (Choice C) may provide comfort but does not address the underlying cause. Providing a clear liquid diet (Choice D) is not ideal for diverticulitis management as it lacks the necessary nutrients for healing and may not provide enough bulk to prevent further irritation.

Correct Answer: C

Rationale: The correct answer is C. A weight gain of 2.2 kg (5 lb) in 1 week can indicate fluid retention, a serious side effect of fluoxetine that should be reported to the provider. Choices A, B, and D are within normal ranges and are not alarming findings that would require immediate reporting to the provider. A heart rate of 80/min, blood pressure of 130/80 mm Hg, and a temperature of 37.2°C (99°F) are all within normal limits and not typically concerning in a client taking fluoxetine.

Correct Answer: D

Rationale: The correct answer is D, a history of allergy to shellfish. A known allergy to shellfish is a contraindication for the use of contrast media in a CT scan due to the potential risk of an allergic reaction, which could be severe and life-threatening. Choices A, B, and C are not contraindications to the procedure. A normal white blood cell count, urine specific gravity within the normal range, and a history of asthma do not typically interfere with the administration of contrast media for a CT scan.

Correct Answer: A

Rationale: The correct answer is A because clients taking warfarin should have their INR (International Normalized Ratio) checked regularly to monitor the medication's effectiveness and adjust the dose if needed. This monitoring helps to ensure the medication is working correctly and the client is within the therapeutic range. Choice B is incorrect because clients on warfarin should not avoid leafy green vegetables but should maintain a consistent intake. Leafy green vegetables contain vitamin K, which can affect warfarin, so it's important to maintain a consistent intake to keep INR stable. Choice C is incorrect as clients should not stop taking warfarin abruptly without consulting their healthcare provider as it can lead to serious health risks like blood clots. Choice D is incorrect because while taking warfarin, it is important to avoid unnecessary aspirin use due to an increased risk of bleeding. However, this statement does not indicate an understanding of the teaching about the need for regular INR monitoring.

Correct Answer: C

Rationale: The correct action for the nurse to take is to administer naloxone if the client's respiratory rate falls below 10/min. Naloxone is used to reverse opioid-induced respiratory depression, which is a life-threatening situation. Monitoring the client's blood pressure every 4 hours (Choice A) is not the priority in this scenario as respiratory depression requires immediate attention. Asking the client to rate their pain every 2 hours (Choice B) is important for pain management but addressing respiratory depression takes precedence. Evaluating the client's use of the PCA every 4 hours (Choice D) is a routine nursing intervention but does not directly address the urgent need to reverse respiratory depression in this case.