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: B

Rationale: Ventricular fibrillation is the dysrhythmia most commonly associated with sudden cardiac death (SCD). Ventricular fibrillation is a rapid, chaotic, and disorganized electrical activity in the ventricles that leads to ineffective contraction. This dysrhythmia can quickly progress to hemodynamic collapse and ultimately cardiac arrest, resulting in sudden cardiac death if not promptly treated with defibrillation. Atrial flutter, paroxysmal supraventricular tachycardia, and junctional escape rhythm are not typically associated with as high a risk of sudden cardiac death as ventricular fibrillation.

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: D

Rationale: Breaking the information into small sessions to enhance learning is the most effective approach when organizing the teaching experience for a client with a new permanent colostomy. This allows for better retention of information as the client can focus on a few key points at a time and then progressively build upon that knowledge. By breaking the information into smaller sessions, the nurse can ensure that the client fully understands each aspect of colostomy care before moving on to the next topic. This method promotes better understanding, leads to improved compliance with care instructions, and ultimately contributes to better outcomes for the client.

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.