Correct Answer: C

Rationale: In a client with right-sided heart failure, crackles in the lungs are the most concerning finding as they indicate pulmonary congestion, which requires immediate intervention. Crackles suggest fluid accumulation in the lungs, leading to impaired gas exchange and potential respiratory distress. Jugular venous distention (Choice A) and peripheral edema (Choice B) are common findings in right-sided heart failure but do not indicate acute deterioration requiring immediate intervention. Elevated liver enzymes (Choice D) may be seen in chronic heart failure but do not warrant immediate action compared to the urgent need to address pulmonary congestion indicated by crackles in the lungs.

Correct Answer: C

Rationale: The correct answer is C. Use of accessory muscles is the most concerning finding in a client with COPD experiencing an exacerbation. This indicates increased work of breathing and can be a sign of respiratory failure, requiring immediate intervention. Oxygen saturation of 90% is low but not as concerning as the increased work of breathing. A respiratory rate of 24 breaths per minute can be within normal limits. Inspiratory crackles may be present in COPD due to airway inflammation but are not as concerning as the use of accessory muscles.

Correct Answer: C

Rationale: The client with viral meningitis and a temperature change is the most stable and appropriate for assignment to the PN. A change in temperature from 101°F to 102°F is not as critical as changes in Glasgow Coma Scale score, blood pressure, or wider blood pressure variations. The other clients require more complex monitoring and intervention due to their critical changes in status.

Correct Answer: A

Rationale: The correct answer is A: Use of accessory muscles. This finding indicates increased work of breathing in a client with COPD and may signal respiratory failure, requiring immediate intervention. In COPD, the use of accessory muscles suggests that the client is in distress and struggling to breathe effectively. Oxygen saturation of 90% is within an acceptable range for a client with COPD receiving supplemental oxygen and does not require immediate intervention. A respiratory rate of 24 breaths per minute is slightly elevated but not a critical finding. A blood pressure of 110/70 mmHg is within the normal range for an adult and does not indicate a need for immediate intervention in this scenario.

Correct Answer: A

Rationale: An increase in temperature during a transfusion may indicate a transfusion reaction, which can be serious. Stopping the transfusion and starting a saline infusion is the priority action to prevent further complications and address the potential adverse reaction. Administering antipyretics (choice B) may mask the symptoms of a transfusion reaction, delaying appropriate treatment. While monitoring vital signs (choice C) is important, stopping the transfusion takes precedence to prevent harm. Notifying the healthcare provider (choice D) is essential but should not delay the immediate intervention of stopping the transfusion and starting a saline infusion.