A patient has end-stage dilated cardiomyopathy. He comes to the emergency department with dyspnea. He says he went to bed and awoke with a feeling of suffocation. He says it was frightening. Which of the ff. responses by the nurse is most appropriate?

Correct Answer: C

Rationale: The most appropriate response by the nurse is option C, "Reclining increases fluid returning to the heart, which builds up fluid in the lungs." In a patient with end-stage dilated cardiomyopathy, reclining position can lead to increased fluid return to the heart due to the failing pump function. This can result in fluid backing up in the lungs, causing symptoms such as dyspnea or feeling of suffocation. By explaining this mechanism to the patient, the nurse can provide valuable information about the condition and the reason for the distressing symptoms experienced by the patient. It also highlights the importance of proper positioning to alleviate symptoms and improve the patient's comfort.

Correct Answer: D

Rationale: Passive immunization involves the administration of pre-formed antibodies rather than stimulating the individual's immune system to produce its own antibodies (active immunization). In the case of a pregnant client requiring immediate but temporary protection from chickenpox, passive immunization would be the most appropriate choice. This is because passive immunization can provide immediate protection without activating the pregnant individual's immune system, which could pose potential risks during pregnancy. By introducing pre-formed antibodies against chickenpox, the pregnant client can acquire temporary immunity to the virus, safeguarding both her and her developing baby.

Correct Answer: C

Rationale: The most appropriate nursing action for infection control when caring for a patient with AIDS is to wear gloves for blood/body fluid contact. HIV, the virus that causes AIDS, is primarily spread through exposure to infected blood or body fluids. Therefore, wearing gloves when there is a potential for blood or body fluid contact is crucial in preventing the transmission of the virus. Wearing gloves at all times may not be necessary if there is no direct contact with blood or body fluids, and wearing a gown and mask at all times may not be indicated unless there is a specific need based on the situation. Wearing a mask during patient contact times may also not be necessary unless there is a risk of exposure to respiratory secretions.

Correct Answer: C

Rationale: Monitoring body temperature is important in clients with systemic lupus erythematosus (SLE) because fever can indicate an infection or a disease flare-up. Clients with SLE are at higher risk of infections due to their compromised immune system, and fever can be a sign of an underlying issue that needs prompt attention. It is essential for the nurse to educate the client about monitoring body temperature regularly and seeking medical advice if there is a sudden increase in temperature.

Correct Answer: C

Rationale: In a client with end-stage acquired immunodeficiency syndrome (AIDS) manifesting with profound Cryptosporidium infection, fluid replacement is crucial for managing the symptoms and complications. Cryptosporidium infection can cause severe diarrhea and dehydration, leading to significant fluid loss. Therefore, the primary focus of care in this situation should be on maintaining adequate hydration through fluid replacement. This is essential for preventing further complications and supporting the client's overall health and well-being. Pain management, antiretroviral therapy, and high-calorie intake may be important aspects of care in other situations but are not the priority in managing a client with severe Cryptosporidium infection and dehydration.