The nurse is caring for four clients: Client A, who has emphysema and an oxygen saturation of 94%; Client B, with a postoperative hemoglobin of 8.7 g/dL; Client C, newly admitted with a potassium level of 3.8 mEq/L; and Client D, scheduled for an appendectomy with a white blood cell count of 15,000/mm3. What intervention should the nurse implement?

Correct Answer: D

Rationale: The correct answer is D because a white blood cell count of 15,000/mm3 indicates an infection, which can be a contraindication for surgery. The nurse should inform Client D that surgery is likely to be delayed until the infection is treated to prevent complications. Choice A is incorrect as increasing oxygen for Client A may not be necessary based on the oxygen saturation level of 94%, which is within the normal range. Choice B is incorrect because determining if packed cells are available in the blood bank for Client B with a hemoglobin of 8.7 g/dL does not address the immediate concern of the possible surgical delay due to infection. Choice C is incorrect as adding a banana to Client C's breakfast tray for a potassium level of 3.8 mEq/L is not a priority compared to addressing the potential surgical delay for Client D.

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: D

Rationale: Rationale: Option D is the correct answer because it directly addresses the client's experience with penicillin, providing crucial details about the allergic reaction. By asking what happens when the client takes penicillin, the nurse gains specific information to assess the severity and type of allergic reaction. This helps in determining appropriate interventions and alternative medications. Options A, B, and C are incorrect as they do not focus on gathering detailed information about the client's allergic reaction to penicillin. Option A is too broad, option B is not relevant to the current situation, and option C does not directly address the client's individual experience.

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.