A nurse is reinforcing discharge teaching with a client who has heart failure. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

D. Place the client in high Fowler’s position. Positioning the client upright maximizes lung expansion and improves oxygenation. This is the first step to alleviate respiratory distress before additional interventions.

A. Administer oxygen to the client. Once the client is positioned appropriately, providing supplemental oxygen helps increase oxygen saturation and relieve hypoxia. The nurse should titrate oxygen as needed according to facility protocols or provider orders.

B. Notify the charge nurse. After immediate interventions are in place, the nurse should inform the charge nurse to ensure further assessment and necessary medical interventions. The charge nurse may escalate care or contact the provider for additional management.

C. Document client findings and interventions taken. Once the client’s condition has been addressed and reported, documentation is necessary to record assessment findings, interventions provided, and the client's response. Accurate documentation ensures continuity of care and legal protection.

A. Administer granulocyte colony-stimulating factor. This medication stimulates neutrophil production in clients with severe neutropenia, such as those undergoing chemotherapy. While HIV can cause neutropenia, routine administration is not necessary unless the infant has recurrent infections and significantly low neutrophil counts.
B. Monitor the infant's lymphocyte count. CD4+ T-cell levels are key indicators of immune function in infants with HIV. Since HIV targets these cells, regular monitoring helps assess disease progression and the effectiveness of antiretroviral therapy, guiding treatment adjustments when needed.
C. Educate the infant's guardians about exchange transfusions. Exchange transfusions are used for conditions like severe neonatal hyperbilirubinemia or sickle cell disease, not HIV. Managing HIV in infants focuses on early antiretroviral therapy, routine lab monitoring, and infection prevention.
D. Initiate droplet precautions. Standard precautions, such as hand hygiene and appropriate use of personal protective equipment, are sufficient for infection control. HIV is not transmitted through respiratory droplets but through direct contact with infected blood, breast milk, or other bodily fluids.