A patient asks the nurse what her diagnosis of heart failure means. Which of the ff. is the nurse’s best response?

Correct Answer: D

Rationale: The correct answer is D: “Your heart is not an efficient pump.” This response is the best choice as it accurately describes heart failure, which is a condition where the heart is unable to pump blood effectively. This leads to symptoms such as fatigue, shortness of breath, and fluid retention. Explanation: 1. Choice A is incorrect because heart failure does not mean the heart stops; it means the heart is not functioning properly. 2. Choice B is incorrect because heart failure does not necessarily mean there is dead muscle tissue in the heart. 3. Choice C is incorrect because heart failure is not about pumping too much blood; it is about the heart's inability to pump blood efficiently, leading to circulation problems and other symptoms.

Correct Answer: B

Rationale: The correct answer is B because monitoring the site and progress of the infusion every hour is crucial to prevent complications like infiltration or infection in clients with hypertension. Choice A is incorrect as checking BP every hour is excessive. Choice C is incorrect as daily monitoring may not detect issues promptly. Choice D is incorrect as pulse rate monitoring is not directly related to IV fluid administration in this context. Monitoring the site and progress hourly ensures timely intervention if any issues arise.

Correct Answer: A

Rationale: The correct answer is A because providing clear liquids only until the patient can swallow solid foods is not a recommended nursing intervention to prevent aspiration. Clear liquids do not require the same level of swallowing coordination as solid foods, so it may not help improve swallowing ability. B: Having the patient swallow twice after each bite can help clear the throat and reduce the risk of aspiration. C: Placing food on the unaffected side of the mouth can help direct the food towards the stronger side for swallowing. D: Checking the patient's mouth for pocketing of food is important to ensure that food is not being retained in the mouth, which could lead to aspiration.

Correct Answer: C

Rationale: Rationale: Choice C is correct because antibodies are indeed produced by B-cells as part of the adaptive immune response. B-cells differentiate into plasma cells that produce antibodies to target specific antigens. This process is essential for generating immunity against pathogens. Incorrect Choices: A: Antibody-mediated defense occurs through the B-cell system, not the T-cell system. T-cells are involved in cell-mediated immunity. B: Cellular immunity is mediated by T-cells, not antibodies produced by B-cells. T-cells directly attack infected cells. D: Lymphocytes can increase during an allergic response, but this does not specifically relate to immunity through antibody production by B-cells.

Correct Answer: A

Rationale: The correct initial action for the nurse to take is A: Try to have the client breathe slower. This is because the client may be experiencing respiratory distress, and slowing down their breathing can help improve oxygenation. Giving O2 via nasal cannula (B) should be considered if the client's oxygen saturation is low after trying to slow down their breathing. Administering sodium bicarbonate (C) is not the appropriate initial action unless the client is experiencing severe acidosis. Monitoring the client's fluid balance (D) is important but not the best initial action in this scenario where respiratory distress is the concern.