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: 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: 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: 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: 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.