When evaluating a client's understanding of wearing a Holter monitor, which statement made by the client would indicate to the nurse that the client understands the procedure?

Correct Answer: A

Rationale: The correct answer is A because it demonstrates the client understands the purpose of wearing a Holter monitor—to record symptoms related to activity. This shows the client comprehends the importance of monitoring symptoms accurately. Choices B, C, and D are incorrect because they do not relate to the purpose of wearing a Holter monitor or indicate an understanding of the procedure. B focuses on personal preference, C on unrelated procedures, and D on irrelevant safety precautions.

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: C

Rationale: The correct answer is C: Contact a person of the client's choosing to remove the weapon from the home. This option respects the client's autonomy and confidentiality while ensuring her safety. 1. Encouraging the client to remove the gun (Option A) may not guarantee immediate action and could potentially escalate the situation. 2. Notifying the client's healthcare provider (Option B) could breach confidentiality and may not result in immediate intervention. 3. Calling the police (Option D) could lead to a loss of trust and may not be necessary if the situation can be handled discreetly by someone the client trusts. Therefore, option C is the best course of action as it respects the client's autonomy, maintains confidentiality, and ensures prompt removal of the weapon to enhance the client's safety.

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.