What does a nurse assess postoperatively in a client with a nasal fracture?

Correct Answer: C

Rationale: Postoperatively in a client with a nasal fracture, a nurse would assess for airway obstruction. Nasal fractures can cause swelling, bleeding, and obstruction of the nasal passages, which could potentially compromise the client's ability to breathe. Monitoring for signs of airway compromise, such as difficulty breathing, stridor, or other respiratory distress, is crucial in the postoperative period to ensure prompt intervention if necessary. Assessing for airway patency is a priority to prevent any serious complications related to impaired breathing. While allergic reaction, extreme sense of smell, or stridor may occur in some cases, airway obstruction is the most critical concern that requires immediate attention to maintain the client's respiratory function.

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: A

Rationale: The mother in this scenario had chickenpox as a child, which means she was exposed to the virus and developed immunity through her own immune response. This type of immunity acquired as a result of natural exposure to an infectious agent is called active natural immunity. In this case, the mother's immune system "learned" how to recognize and fight off the chickenpox virus when she was previously infected, leading to the development of memory cells that provide long-lasting protection against future infections.

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.