Fundamental Concepts and Skills for Nursing 6th Edition Test Bank

Correct Answer: C

Rationale: In stage III of heart failure, the client displays symptoms such as dyspnea, fatigue, and other symptoms with ordinary physical activity, known as NYHA Class III. This is consistent with the client's presentation of dyspnea with activities of daily living, indicating a moderate level of heart failure. The need for the placement of an implantable defibrillator also suggests a more advanced stage of heart failure compared to stage I or II. Stage IV is characterized by severe symptoms at rest, which the client does not exhibit based on the information provided.

Correct Answer: C

Rationale: Chvostek�s sign is an assessment technique used to detect hypocalcemia. The nurse will tap lightly over the facial nerve, just in front of the patient�s ear. A positive Chvostek�s sign is indicated by a twitching of the facial muscles on the same side of the face as the area that was tapped. This twitching is due to the hyperexcitability of the facial nerve, which can be a sign of low calcium levels. Therefore, option C is the correct way to conduct the assessment for Chvostek�s sign.

Correct Answer: A

Rationale: This statement indicates a need for additional teaching because in a client with preeclampsia, dark and reduced urine output could be a sign of kidney involvement and impaired kidney function. In preeclampsia, monitoring urine output, particularly for signs of proteinuria, is crucial as it can indicate worsening of the condition and potential damage to the kidneys. Therefore, the client should be educated that changes in urine color and amount should be reported to the healthcare provider promptly.

Correct Answer: B

Rationale: The correct answer is B. The statement "I need to use a soft toothbrush and an electric razor to avoid injuries" indicates that the client understands the importance of preventive measures to minimize bleeding risks while on anticoagulant therapy. Using a soft toothbrush and an electric razor can help prevent accidental cuts that may lead to bleeding complications. It shows the client's understanding of the need to take precautions to avoid potential harm while on long-term anticoagulant therapy. The other statements do not directly address safety measures to prevent bleeding complications associated with anticoagulant therapy.

Correct Answer: A

Rationale: Encouraging oral intake of fluids when permitted is the most appropriate intervention to support the pediatric client's fluid status post-surgery. Adequate hydration is essential for the recovery process, and oral intake of fluids helps maintain fluid balance. Limiting oral and intravenous intake of fluids (option B) would not be beneficial in promoting hydration and recovery. Continuing normal saline administration even after oral intake is normal (option C) may lead to fluid overload. Converting the intravenous line to a saline lock immediately after surgery (option D) may not be ideal as the client may still need intravenous fluids to support hydration until they can tolerate oral intake effectively.