Correct Answer: A

Rationale: The correct answer is A: Assess vital signs. Vital signs provide crucial information on the client's overall condition and can help identify any life-threatening issues. Monitoring vital signs such as blood pressure, heart rate, respiratory rate, and temperature can guide immediate interventions and determine the urgency of further assessments or treatments. Administering oxygen (B) would be appropriate after assessing vital signs. Performing an ECG (C) may be indicated later but is not the priority in this acute situation. Monitoring serum glucose levels (D) is not typically the first assessment in a client with severe abdominal pain.

Correct Answer: B

Rationale: The correct answer is B: Monitor INR levels. INR (International Normalized Ratio) is a crucial parameter to monitor for clients on anticoagulant therapy, as it measures the effectiveness of the medication in preventing blood clots. By monitoring INR levels, the nurse can ensure the client is within the therapeutic range to prevent both bleeding and clotting complications. Choice A (Monitor platelet count) is incorrect because anticoagulant therapy does not directly affect platelet count, and monitoring platelets is more relevant for clients on antiplatelet therapy. Choice C (Monitor bleeding) is partially correct, but focusing solely on monitoring bleeding may not provide a comprehensive assessment of the client's response to anticoagulant therapy. Choice D (Monitor renal function) is incorrect as anticoagulant therapy primarily affects coagulation factors and not renal function. Renal function monitoring may be necessary for certain medications but is not a primary consideration for anticoagulant therapy.

Correct Answer: A

Rationale: The correct answer is A: Assess vital signs. Vital signs provide crucial information on the client's overall condition and can help identify any life-threatening issues. Monitoring vital signs such as blood pressure, heart rate, respiratory rate, and temperature can guide immediate interventions and determine the urgency of further assessments or treatments. Administering oxygen (B) would be appropriate after assessing vital signs. Performing an ECG (C) may be indicated later but is not the priority in this acute situation. Monitoring serum glucose levels (D) is not typically the first assessment in a client with severe abdominal pain.

Correct Answer: D

Rationale: The correct answer is D. A client with renal disease must avoid foods high in potassium to prevent hyperkalemia, as the kidneys are unable to properly filter and excrete potassium. Foods high in potassium can lead to dangerous levels of potassium in the blood, which can be life-threatening for individuals with renal disease. Choice A is incorrect because a client receiving diuretic therapy may actually need to increase their potassium intake due to the potassium-wasting effects of diuretics. Choice B is incorrect as having an ileostomy does not necessarily affect potassium levels. Choice C is incorrect because clients with metabolic alkalosis may actually benefit from consuming foods high in potassium to help correct the acid-base imbalance.

Correct Answer: D

Rationale: The correct answer is D: Level of consciousness and cognitive abilities. In this scenario, the individual is experiencing delirium due to fluid and electrolyte imbalance, which can affect his level of consciousness and cognitive abilities. Assessing these aspects is crucial in determining the severity of the condition and guiding appropriate interventions. Option A (Affect and mood) is incorrect as the primary concern is the individual's cognitive functioning. Option B (Memory and affect) is incorrect as it does not cover the assessment of consciousness. Option C (Thought processes and memory) is incorrect as it does not specifically address the evaluation of the individual's level of consciousness.