The breakdown in teamwork is often times a failure in:

Correct Answer: D

Rationale: The correct answer is D: Communication. Effective communication is essential for teamwork to function smoothly. Without clear and open communication among team members, misunderstandings, conflicts, and lack of coordination can arise, leading to breakdowns in teamwork. Adequate communication ensures that team members are on the same page, understand their roles and responsibilities, and can collaborate effectively. Choices A, B, and C are incorrect as they do not directly address the root cause of teamwork breakdown, which is the lack of communication.

Correct Answer: B

Rationale: The correct answer is B, "In the operating room." This is because applying the drainage appliance to the stoma immediately after the ileostomy creation in the operating room allows for immediate containment of effluent and reduces the risk of skin irritation or infection. Choice A is incorrect as immediate application is necessary to prevent skin damage. Choice C is incorrect because waiting for the ileostomy to begin functioning can lead to effluent coming into contact with the skin. Choice D is incorrect as self-care procedures should be initiated after application of the drainage appliance to ensure proper stoma care.

Correct Answer: B

Rationale: The correct answer is B: Avoid foods high in vitamin K. Anticoagulants work by preventing blood clotting, and vitamin K is essential for blood clotting. Consuming foods high in vitamin K can interfere with the effectiveness of the anticoagulant medication, leading to potential bleeding risks. Therefore, the nurse should educate the client to avoid such foods to maintain the therapeutic levels of the anticoagulant. Incorrect choices: A: Reporting incidents of diarrhea is important but not directly related to anticoagulant therapy. C: Using a straight razor when shaving can increase the risk of cuts and bleeding, which is contraindicated for a client on anticoagulants. D: Taking aspirin for pain relief is not recommended for a client on anticoagulants due to the increased risk of bleeding.

Correct Answer: B

Rationale: The correct response is to place a saline-soaked sterile dressing on the wound. This step helps to prevent infection, maintain moisture, and protect the exposed tissues. Calling the physician is important, but immediate action to cover the wound is crucial. Taking blood pressure and pulse can wait until the wound is stabilized. Pulling the dehiscence closed can cause further damage and should not be done by the nurse.

Correct Answer: C

Rationale: The correct answer is C: Pneumonia. Given the client's symptoms of fever, cough with yellow sputum, pleuritic chest pain, and dehydration, pneumonia is the most likely diagnosis. Fever, productive cough, and chest pain are common symptoms of pneumonia. The presence of pleuritic chest pain indicates an inflammation of the pleura, which is a common feature of pneumonia. Dehydration can also contribute to the development of pneumonia. ARDS (choice A) typically presents with acute respiratory distress and is not supported by the client's symptoms. MI (choice B) presents with chest pain but typically not associated with fever, cough, or sputum production. Tuberculosis (choice D) can present with cough and sputum production but is less likely given the client's age and acute presentation.