Fundamental Concepts and Skills for Nursing 6th Edition Test Bank

Correct Answer: C

Rationale: Patients with deep venous thrombosis (DVT) are at risk for developing a complication known as pulmonary embolism, which is a potentially life-threatening condition. A pulmonary embolism occurs when a blood clot dislodges from the veins, typically in the legs, and travels to the lungs, blocking blood flow. This can lead to respiratory symptoms such as shortness of breath, chest pain, and in severe cases, respiratory failure. Therefore, it is essential for the nurse to carefully monitor the respiratory system in a patient with DVT to promptly identify any signs of pulmonary embolism and initiate appropriate interventions to prevent further complications.

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: 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.

Correct Answer: B

Rationale: When a client is in shock, their body is not able to regulate its temperature effectively. In this situation, using warm IV fluids helps prevent hypothermia by providing the body with fluids at a temperature closer to the body's normal core temperature. Hypothermia can worsen the condition of a client in shock by further compromising their body's ability to maintain adequate perfusion and oxygen delivery to tissues. Therefore, utilizing warm IV fluids is essential in the resuscitation of clients in shock to help maintain their core body temperature within a suitable range.

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.