Correct Answer: D

Rationale: An elevated INR in clients taking warfarin increases the risk of bleeding. The nurse should notify the healthcare provider immediately and hold the next dose of warfarin to prevent complications.

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.

Correct Answer: A

Rationale: Urine specific gravity is the most accurate indicator of hydration status in this scenario.

Correct Answer: C

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

Correct Answer: D

Rationale: Tetanus causes severe muscle spasms and sensitivity to stimuli, so minimizing stimuli like light, sound, and touch can help prevent painful spasms. Monitoring vital signs and administering antibiotics are important but managing stimuli is crucial for the child's comfort and safety.