While planning for proportionate distribution of restricted fluid volumes, what is the reason for a nurse to ensure that the client is actively involved during the development of the plan?

Correct Answer: A

Rationale: It is essential for a nurse to ensure that the client is actively involved in the development of the plan for proportionate distribution of restricted fluid volumes because it promotes the client's compliance with therapy. When the client participates in creating the plan, they are more likely to understand the importance of following it and be motivated to adhere to the recommended fluid restrictions. This active involvement fosters a sense of ownership and responsibility, leading to better treatment outcomes and improved overall health.

Correct Answer: C

Rationale: Three-year-olds are literal thinkers; if they see a body, they may assume that the person is still present.

Correct Answer: B

Rationale: The nurse should explain to the baby's parents that the ventricular septal defect will likely close without therapy. Small ventricular septal defects have a high likelihood of closing on their own as the child grows. Surgical intervention is usually not necessary for small defects, especially when the baby does not exhibit signs of congestive heart failure. It is important for the parents to be aware of the natural course of the defect and to follow up with the healthcare provider for monitoring and management.

Correct Answer: B

Rationale: A PT level of 26 seconds is significantly above the normal range of 9 to 12 seconds. This indicates that the patient's blood is taking much longer to clot than usual, which may put the patient at risk for bleeding. It is important for the nurse to inform the physician before giving the next dose of warfarin because warfarin is a medication that helps prevent blood clots by thinning the blood. However, in this case, the patient's blood is already thin beyond the target range, so giving the next dose of warfarin without physician guidance may further increase the risk of bleeding. The physician may need to adjust the dose or recommend other interventions to manage the patient's PT levels effectively.

Correct Answer: A

Rationale: Nosocomial pneumonia occurs in a healthcare setting. It is a type of pneumonia that is contracted during a hospital stay or other healthcare facilities. The risk of developing nosocomial pneumonia is higher in patients who are already hospitalized due to various medical conditions, surgeries, or use of medical devices like ventilators. The infection can be caused by different types of bacteria, viruses, or fungi present in the healthcare environment. Preventive measures, such as proper hand hygiene, infection control practices, and minimizing the use of invasive devices, are crucial in reducing the incidence of nosocomial pneumonia.