Fundamental Concepts and Skills for Nursing 6th Edition Test Bank

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: Acute kidney injury (AKI) is a common complication in critically ill patients in the intensive care unit (ICU). One of the primary interventions to reduce the risk of AKI is to maintain adequate fluid volume and cardiac output. Adequate hydration and adequate perfusion pressure are essential for renal function. Maintaining fluid volume and adequate cardiac output ensure that the kidneys receive enough blood flow and oxygen to function optimally. Conversely, inadequate fluid volume or low cardiac output can lead to decreased renal perfusion, predisposing the patient to AKI. Monitoring and optimizing fluid status and cardiac output are crucial in preventing AKI in high-risk patients in the ICU.

Correct Answer: A

Rationale: Option A is the most appropriate response by the nurse because it provides accurate information related to the client's concern about developing coronary artery disease. Studies have shown that women who take oral contraceptives have an increased risk of developing cardiovascular issues, including coronary artery disease. By providing this information, the nurse addresses the client's statement and educates her about a potential risk factor for the disease. This empowers the client with knowledge that can help her understand the possible reasons behind her diagnosis and make informed decisions about her health moving forward.

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: 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.