In which situation is it most important for the registered nurse (RN) working on a medical unit to provide direct supervision?

Correct Answer: A

Rationale: The correct answer is A because accessing an implanted port for infusion is a specialized skill that requires direct supervision to ensure the safety and accuracy of the procedure. Step 1: A graduate nurse may not have sufficient experience with accessing ports. Step 2: The RN needs to ensure proper technique and prevent complications. Step 3: Direct supervision allows for immediate intervention if any issues arise. Other choices are incorrect because B: starting a transfusion is within the scope of practice for a nurse, C: assisting with a lumbar puncture can be done under indirect supervision, and D: weighing a client is a task that can be delegated to unlicensed personnel with proper training.

Correct Answer: A

Rationale: The correct answer is A: Decreased urine specific gravity. In diabetes insipidus, there is an inability to concentrate urine, leading to decreased urine specific gravity. This is due to the decreased production or action of antidiuretic hormone (ADH). As a result, the kidneys are unable to reabsorb water efficiently, causing dilute urine with low specific gravity. Incorrect choices: B: Elevated urine glucose is more indicative of diabetes mellitus, not diabetes insipidus. C: Decreased serum potassium is not a typical finding in diabetes insipidus. D: Increased serum sodium can occur due to dehydration from excessive urination in diabetes insipidus, but it is not directly indicative of the condition.

Correct Answer: D

Rationale: The correct answer is D: Maintain a protective isolation environment. During bone marrow repopulation after transplantation, the client is at high risk of infection due to compromised immune function. By maintaining a protective isolation environment, the nurse can minimize the risk of exposure to pathogens that could lead to infections. This intervention helps prevent potential complications and supports the client's recovery. Rationale for other choices: A: Administering sargramostim may enhance white blood cell production but does not directly address the risk of infection during bone marrow repopulation. B: Infusing PRBC and platelet transfusions may be necessary for managing anemia and thrombocytopenia but does not address the priority of infection prevention. C: Giving prophylactic antibiotics may be beneficial in some cases, but maintaining a protective isolation environment is the priority to reduce the risk of infection in this immunocompromised client.

Correct Answer: B

Rationale: The correct answer is B: Increase the client's IV fluid rate to 200 ml/hr. The client's vital signs indicate hypotension, tachycardia, decreased urine output, and cool skin, suggesting hypovolemic shock. Increasing IV fluid rate will help to restore intravascular volume and improve perfusion to vital organs. This is the highest priority as it addresses the immediate physiological need for circulatory support. Choice A is incorrect because hypothermia is not indicated based on the client's presentation. Choice C is incorrect as it does not address the client's urgent physiological needs. Choice D is incorrect as drawing blood cultures, while important, is not the most immediate priority in this situation.

Correct Answer: A

Rationale: The correct answer is A: Check the blood glucose level. This is the first action the nurse should take because the client is presenting with symptoms of hypoglycemia, which can be life-threatening for a pregnant woman with Type 1 diabetes. By checking the blood glucose level, the nurse can determine if the client's symptoms are due to low blood sugar levels and take appropriate action. Drawing blood for a Hemoglobin A1C (choice B) is not the first priority in this acute situation. Assessing urine for ketone levels (choice C) is important in managing diabetes but is not the priority when the client is showing signs of hypoglycemia. Providing the client with a protein snack (choice D) may help raise blood sugar levels, but checking the blood glucose level is essential to determine the appropriate intervention.