Correct Answer: B

Rationale: Tetralogy of Fallot (TOF) involves four cardiac defects, as described in option B: pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta. These four defects result in mixing of oxygen-poor and oxygen-rich blood in the heart, leading to decreased oxygen levels in the blood that is pumped to the body. This characteristic results in cyanosis (blue discoloration of the skin). Providing accurate information about the specific defects involved in TOF helps parents understand the complexity and potential complications associated with their child's condition. This knowledge can aid in their ability to recognize symptoms and seek timely medical intervention when needed.

Correct Answer: C

Rationale: Sulfasalazine can cause photosensitivity, making the patient more prone to sunburn. Therefore, it is important for patients taking sulfasalazine to use sunscreen to protect their skin from harmful UV rays. This can help prevent sunburn and skin damage while on the medication. It is not necessary to take vitamin C with this drug, take it on an empty stomach, or limit fluid intake to 1500 mL per day.

Correct Answer: A

Rationale: Direct observation of behavior is the best way for the nurse to evaluate whether the client is able to set up and administer a nebulizer treatment. By directly observing the client, the nurse can assess the client's understanding and ability in performing the necessary steps correctly and safely. This approach allows for real-time evaluation and correction if needed, ensuring that the client can effectively manage their nebulizer treatment at home. Written or oral descriptions may not accurately reflect the client's actual competency in performing the task, and relying on the client's self-report during a follow-up appointment may not provide a complete picture of their ability.

Correct Answer: C

Rationale: Activity intolerance is the most appropriate nursing diagnosis for a client with cardiomyopathy who becomes short of breath with ambulation and eating and fatigued with routine care activities. Cardiomyopathy is a condition where the heart muscle becomes weakened, affecting its ability to pump blood effectively. As a result, the client may experience symptoms such as shortness of breath, fatigue, and decreased tolerance for physical activity. By identifying activity intolerance as a nursing diagnosis, the nurse can focus on addressing the client's limitations in performing activities and developing a plan of care to help improve the client's endurance and functional ability.

Correct Answer: D

Rationale: The client recovering from knee replacement surgery has the greatest risk for developing deep venous thrombosis (DVT). Knee replacement surgery is a major orthopedic procedure that involves prolonged immobility and disruption of the normal blood flow in the lower extremities, which increases the risk of developing DVT. Postoperative patients are at a higher risk for developing blood clots due to reduced mobility, surgical trauma, and alterations in blood flow. Therefore, it is essential for healthcare providers to implement preventive measures to reduce the risk of DVT, such as early mobilization, compression stockings, and pharmacological prophylaxis.