The nurse is caring for a client with disseminated intravascular coagulation (DIC). Which should the nurse identify as a priority intervention for this 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.

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: 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: B

Rationale: The correct answer is B. The statement "I need to use a soft toothbrush and an electric razor to avoid injuries" indicates that the client understands the importance of preventive measures to minimize bleeding risks while on anticoagulant therapy. Using a soft toothbrush and an electric razor can help prevent accidental cuts that may lead to bleeding complications. It shows the client's understanding of the need to take precautions to avoid potential harm while on long-term anticoagulant therapy. The other statements do not directly address safety measures to prevent bleeding complications associated with anticoagulant therapy.

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.