Correct Answer: D

Rationale: When a client has an alteration in perfusion, particularly with inadequate oxygenation, positioning to increase blood return is essential in maintaining adequate tissue perfusion and oxygenation. By positioning the client in a way that maximizes venous return to the heart, the nurse can optimize cardiac output and improve oxygen delivery to the tissues. This can include elevating the legs slightly to facilitate blood return from the lower extremities, ensuring proper alignment of the body to prevent compression of major vessels, and promoting proper body mechanics to reduce the workload on the heart. Encouraging ambulation, instructing on deep breathing, and administering medications to increase heart rate may all have their place in certain scenarios, but for a client at risk for inadequate oxygenation due to perfusion issues, positioning to optimize blood return is the most crucial consideration.

Correct Answer: D

Rationale: Virchow's triad describes the three pathological factors that are associated with the formation of a thrombus. These factors include endothelial injury, abnormal blood flow, and hypercoagulability. Endothelial injury disrupts the normal function of the endothelium, leading to the exposure of collagen and tissue factor, which triggers the coagulation cascade. Abnormal blood flow can result in stasis or turbulence, which promotes the accumulation of platelets and clotting factors. Hypercoagulability refers to an increase in the tendency of the blood to clot, which can be caused by various conditions such as genetic disorders, cancer, and certain medications. These three factors work together to increase the risk of thrombus formation.

Correct Answer: B

Rationale: The correct statement indicating that teaching was effective is "It's a protein that pulls water into my blood vessels." Albumin is a type of protein found in the blood that helps to maintain blood volume and pressure by pulling water into the blood vessels from surrounding tissues. In the case of a client recovering from hypovolemic shock, infusion of albumin 5% can help to restore blood volume and improve circulation. The other statements do not accurately describe the function of albumin in the body.

Correct Answer: B

Rationale: In this situation, the nursing diagnosis of Ineffective Health Management is of the greatest initial importance when planning care. The client's inability to afford medications due to financial constraints directly affects their ability to manage their health effectively. Lack of funds may lead to non-adherence to the prescribed treatment plan, which can worsen the client's condition. By addressing the financial barriers to medication access, the nurse can help the client improve their health management and outcomes. This nursing diagnosis is a priority as it addresses the immediate need to ensure the client's access to necessary medications and prevent exacerbation of their congestive heart failure.

Correct Answer: A

Rationale: Pain and limited mobility are the most common manifestations of musculoskeletal disorders. Patients with musculoskeletal issues often experience pain, which can be localized to the affected area or radiate to other parts of the body. Pain can range from mild discomfort to severe and debilitating. Limited mobility refers to a decreased range of motion in joints or difficulty moving due to stiffness, weakness, or structural abnormalities. These symptoms can significantly impact a patient's daily activities and quality of life. Pallor, cyanosis, decreased pulses, and exaggerated reflexes are not typically associated with musculoskeletal disorders and may indicate other health conditions.