Fundamental Concepts and Skills for Nursing 6th Edition Test Bank

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: In disseminated intravascular coagulation (DIC), the client experiences widespread clotting throughout the body's small blood vessels, leading to organ damage and bleeding. Maintaining skin integrity is a priority intervention because DIC can cause hemorrhage and increased risk of skin breakdown due to impaired blood circulation. Preventing pressure ulcers and promoting skin health in a client with DIC is crucial to prevent further complications. Frequent ambulation may not be safe for a client with DIC due to the risk of bleeding from compromised blood vessels. Preparation for radiograph procedures and fluid restriction may be necessary interventions depending on the client's condition, but they are not the priority in the immediate care of a client with DIC.

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: The epicardium is the outermost layer of the heart and is also known as the visceral layer of the serous pericardium. It is a thin layer that covers the surface of the heart and is composed of connective tissue and fat. The epicardium helps to protect the heart and provides a smooth outer surface for the heart to move within the pericardial cavity.

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.