Correct Answer: A

Rationale: Encouraging oral intake of fluids when permitted is the most appropriate intervention to support the pediatric client's fluid status post-surgery. Adequate hydration is essential for the recovery process, and oral intake of fluids helps maintain fluid balance. Limiting oral and intravenous intake of fluids (option B) would not be beneficial in promoting hydration and recovery. Continuing normal saline administration even after oral intake is normal (option C) may lead to fluid overload. Converting the intravenous line to a saline lock immediately after surgery (option D) may not be ideal as the client may still need intravenous fluids to support hydration until they can tolerate oral intake effectively.

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: A

Rationale: Option A is the most appropriate response by the nurse because it provides accurate information related to the client's concern about developing coronary artery disease. Studies have shown that women who take oral contraceptives have an increased risk of developing cardiovascular issues, including coronary artery disease. By providing this information, the nurse addresses the client's statement and educates her about a potential risk factor for the disease. This empowers the client with knowledge that can help her understand the possible reasons behind her diagnosis and make informed decisions about her health moving forward.

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.