Correct Answer: A

Rationale: The correct answer is A: Sepsis and respiratory failure. Untreated pneumonia can lead to severe complications such as sepsis, which is a life-threatening response to infection, and respiratory failure, where the lungs can no longer provide enough oxygen to the body. Heart failure and kidney failure (choice B) are not direct complications of untreated pneumonia. Pulmonary embolism and electrolyte imbalance (choice C) are also not commonly associated with untreated pneumonia. Liver failure and electrolyte imbalance (choice D) are not typical complications of pneumonia.

Correct Answer: D

Rationale: The correct answer is D because the inability to perform activities of daily living, such as opening a milk carton, suggests difficulties with fine motor skills. Occupational therapists specialize in helping individuals regain independence in such tasks. Choices A, B, and C do not specifically address fine motor skills related to activities of daily living, therefore not warranting an occupational therapy referral. Choice A mentions lifting the arm, which involves gross motor skills rather than fine motor skills. Choice B involves holding a pencil, which is more related to hand dexterity and strength rather than fine motor skills. Choice C, opening a milk carton, could be related to fine motor skills but is not as clear-cut as the inability described in Choice D, where the frustration is explicitly about the inability to perform a daily living task.

Correct Answer: A

Rationale: The most important consideration in managing a patient with heart failure is to monitor daily weight. This allows healthcare providers to assess fluid retention, adjust medications based on weight changes, and detect early signs of worsening heart failure. While oxygen therapy may be necessary in acute situations, it is not a routine management strategy for stable heart failure patients. Encouraging a low-sodium diet is important to manage fluid retention, but daily weight monitoring is a more direct measure of fluid status. Monitoring for signs of fluid overload is essential, but monitoring daily weight is a proactive approach to detect fluid accumulation before overt symptoms appear.

Correct Answer: B

Rationale: The correct action the nurse should take first when noting excessive lochia discharge in a client who delivered a full-term newborn 16 hours ago is to perform a fundal massage. Fundal massage helps stimulate uterine contractions, which in turn reduces bleeding in postpartum clients. Administering pain medication (Choice A) is not the priority in this situation as addressing the excessive lochia discharge is crucial to prevent complications. Checking the baby's heart rate (Choice C) is important but not the first action to manage the mother's condition. Applying an ice pack (Choice D) is not appropriate for managing excessive lochia discharge; fundal massage is the initial intervention to address this issue effectively.

Correct Answer: C

Rationale: The correct action for the nurse to take is to pour warm water over the client's perineum. This intervention helps stimulate urination after catheter removal by providing warmth and promoting relaxation of the muscles. Assessing for bladder distention after 2 hours (Choice A) is not the initial intervention to facilitate voiding. Encouraging the client to try urinating in a sitting position (Choice B) may be uncomfortable if the client is struggling to void. Restricting the client's fluid intake (Choice D) is not appropriate as it can further exacerbate the issue by concentrating the urine.