Correct Answer: D

Rationale: The correct answer is D. Clients taking warfarin should avoid alcohol and over-the-counter medications without consulting their healthcare provider, as these can interact with warfarin and increase the risk of bleeding. Aspirin, in particular, can exacerbate this risk. Choice A is incorrect because taking warfarin with aspirin can increase the risk of bleeding. Choice B is incorrect as while green leafy vegetables contain vitamin K which can interact with warfarin, it is more important to maintain a consistent intake rather than increase it. Choice C is incorrect because foods high in potassium do not directly impact the bleeding risk associated with warfarin.

Correct Answer: D

Rationale: The correct answer is D because the nurse should document factual, objective information such as the injury sustained by the client. Reporting the specific injury, like a fracture to the left hip, is crucial for accurate medical records. Choices A, B, and C lack specific detail about the injury and focus on different aspects of the fall that are not as pertinent for the health record. Choice A only mentions the fall without specifying the injury, choice B introduces blame without focusing on the client's condition, and choice C adds unnecessary information about the client's pulse which is not directly related to the fall injury.

Correct Answer: C

Rationale: The correct answer is C, 'Diminished breath sounds bilaterally.' This finding should be reported immediately as it could indicate a serious complication such as increased intracranial pressure or respiratory compromise. In a post-craniotomy client, changes in breath sounds may be a sign of developing issues that need prompt intervention. Choices A, B, and D are not as critical in the immediate post-craniotomy period. Pupils equal and reactive to light are expected findings, a sudden increase in urine output may require monitoring but not immediate reporting, and a small increase in blood pressure may not be alarming unless it is significantly high or accompanied by other concerning signs.

Correct Answer: D

Rationale: The correct answer is to monitor the client's potassium level. When administering insulin and glucose in hyperkalemia, the aim is to shift potassium from the bloodstream into the cells, lowering elevated levels. Therefore, monitoring potassium levels closely is essential to prevent hypokalemia or further complications. Monitoring blood glucose levels (Choice A) is important but not the priority in this scenario. Monitoring sodium (Choice B) and calcium levels (Choice C) is not directly related to the treatment of hyperkalemia with insulin and glucose.

Correct Answer: C

Rationale: When a client with rheumatoid arthritis is taking NSAIDs, the nurse should monitor serum creatinine levels. NSAIDs can potentially cause kidney damage, so monitoring creatinine levels helps assess for renal impairment. While monitoring hemoglobin, potassium, and white blood cell count may also be relevant in some cases, serum creatinine is the priority due to the risk of renal complications associated with NSAID use.