Correct Answer: A

Rationale: A serum potassium level of 6.5 mEq/L is most concerning in a client with CKD as it indicates severe hyperkalemia, requiring immediate intervention. Hyperkalemia can lead to life-threatening cardiac arrhythmias. Serum sodium levels within the normal range (135 mEq/L) are not immediately concerning. Serum creatinine of 2.0 mg/dL may indicate impaired kidney function but does not require immediate intervention for hyperkalemia. Blood glucose of 150 mg/dL is within normal limits and does not directly correlate with hyperkalemia in this scenario.

Correct Answer: B

Rationale: Heart disease can affect growth, leading to smaller size in children.

Correct Answer: A

Rationale: The correct answer is A: Nausea and indigestion. Diphenhydramine, an antihistamine, commonly causes gastrointestinal side effects such as nausea and indigestion. These symptoms are often reported by individuals taking this medication. Choices B, C, and D are incorrect because hypersalivation, eyelid and facial twitching, and increased appetite are not typically associated with diphenhydramine use.

Correct Answer: C

Rationale: The correct answer is C, International Normalized Ratio (INR). The INR should be closely monitored in a client prescribed warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range for anticoagulation, reducing the risk of bleeding or clotting complications. Prothrombin time (A) is used to calculate the INR and monitor the effectiveness of warfarin therapy. Hemoglobin level (B) is important but not the primary lab value to monitor when a client is on warfarin. Serum sodium level (D) is not directly related to monitoring warfarin therapy.

Correct Answer: C

Rationale: In this scenario, the most appropriate action for the nurse to take is to request that the mother leave the room. This is important to maintain a calm environment and allow the healthcare team to assess and manage the situation without interference. Option A is not the best choice as it may escalate the situation. Option B, notifying the charge nurse, could be considered after addressing the immediate need to remove the mother from the room. Option D, requesting security to remove her, is not necessary at this point and may further escalate the situation unnecessarily.