Correct Answer: A

Rationale: Maintaining the head of the bed at a 30-degree angle promotes venous drainage from the brain, reducing intracranial pressure in clients with traumatic brain injury.
Choice B is incorrect because suctioning the endotracheal tube every 2 hours is not routine; it should be done only as needed to avoid hypoxia and ICP spikes.
Choice C is incorrect because, while mannitol is used to reduce ICP, its administration is a medical order, not a nursing action, and requires monitoring for side effects.
Choice D is incorrect because hyperventilation is no longer recommended, as it can cause cerebral vasoconstriction, reducing blood flow and worsening brain injury.

Correct Answer: A

Rationale: A potassium level of 3.2 mEq/L is below the normal range (3.5-5.0 mEq/L) and indicates hypokalemia, a common side effect of hydrochlorothiazide (a thiazide diuretic) that can lead to arrhythmias, requiring immediate reporting to the provider.
Choice B is wrong because a blood pressure of 130/80 mm Hg is within the target range for treated hypertension (<140/90 mm Hg) and does not require reporting.
Choice C is wrong because a sodium level of 138 mEq/L is within the normal range (135-145 mEq/L) and is not concerning.
Choice D is wrong because a weight loss of 1 kg in 1 week is not significant and may reflect the diuretic effect of hydrochlorothiazide; significant weight changes (>2 kg in a week) would be more concerning.

Correct Answer: A

Rationale: Applying a cold pack to the surgical site for the first 24 hours reduces swelling and pain, promoting comfort and recovery after total knee arthroplasty.
Choice B is incorrect because keeping the affected leg in a dependent position increases swelling; the leg should be elevated to reduce edema.
Choice C is incorrect because active range-of-motion exercises are typically started later (e.g., day 2 or 3), with passive or assisted exercises on day 1 to avoid strain.
Choice D is incorrect because heparin is usually given subcutaneously (e.g., enoxaparin) for DVT prophylaxis, not IV, and the duration depends on the provider's protocol, not automatically 7 days.

Correct Answer: A

Rationale: An INR of 4.5 is above the therapeutic range for atrial fibrillation (typically 2.0-3.0) and indicates an increased risk of bleeding, requiring immediate reporting to the provider for potential dose adjustment or vitamin K administration.
Choice B is wrong because a platelet count of 200,000/mm3 is within the normal range (150,000-400,000/mm3) and does not require reporting.
Choice C is wrong because aPTT is not used to monitor warfarin therapy (it monitors heparin); an aPTT of 40 seconds is within normal limits (30-40 seconds) and not concerning.
Choice D is wrong because a hemoglobin of 13 g/dL is within the normal range for males (13-17 g/dL) and females (12-16 g/dL) and does not indicate bleeding or anemia.

Correct Answer: C

Rationale: Monitoring for muscle weakness, which may indicate hypokalemia, is critical, as furosemide is a loop diuretic that can cause potassium loss, increasing the risk of arrhythmias in heart failure clients.
Choice A is wrong because clients with heart failure should limit sodium intake to reduce fluid retention, not increase it, to prevent exacerbation of heart failure.
Choice B is wrong because taking furosemide at bedtime is not advised; it should be taken in the morning to avoid nocturia and disrupted sleep due to its diuretic effect.
Choice D is wrong because increasing fluid intake is not recommended for heart failure clients, as it can worsen fluid overload; fluid intake should be guided by the provider based on the client's condition.