A client presents to the emergency department seeking treatment for radiation burns. The nurse should develop the client's plan of care based on which of the following?

The duration of contact with the agent.

The type, dose, and length of exposure.

The pathway of flow through the body.

The temperature to which the skin is heated.

Answer and Explanation

The Correct Answer is B

A. The duration of contact with the agent: While duration is important, it alone does not provide a comprehensive understanding of radiation burns, which require considering the type and dose of radiation as well.

B. The type, dose, and length of exposure: These factors are crucial in assessing the severity and necessary treatment for radiation burns. The type of radiation (e.g., alpha, beta, gamma), the dose

received, and the length of exposure all determine the extent of tissue damage and appropriate interventions.

C. The pathway of flow through the body: This is more relevant to internal contamination with radioactive substances rather than external radiation burns.

D. The temperature to which the skin is heated: Temperature is a factor in thermal burns, not radiation burns. Radiation burns result from energy transfer, not heat.

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Correct Answer is D

Explanation

A. Empty the drainage from the pleuravac at the end of each shift: This is not a standard practice. Chest tube drainage systems typically have a built-in mechanism to handle drainage, and monitoring and recording the output is essential.

B. Report serosanguinous drainage in the pleuravac: Serosanguinous drainage (a mix of blood and serous fluid) can be expected in a hemothorax, especially initially. Reporting is necessary if there are significant changes in the amount or type of drainage.

C. Milk the chest tube every 4 hours to dislodge clotted blood: Milking or stripping the chest tube is generally not recommended as it can create high negative pressures that can damage lung tissue.

D. Assist with coughing and deep breathing exercises every hour: Encouraging coughing and deep breathing helps prevent atelectasis and promotes lung expansion, which is crucial for recovery from a hemothorax.

A. Respond to ventilator alarms. B. Report the absence of spontaneous respirations. C. Encourage the client to take spontaneous breaths. D. Place the call bell within reach.

Correct Answer is B

Explanation

A. Respond to ventilator alarms: Responding to ventilator alarms is important but may not be the priority if the client is not spontaneously breathing.

B. Report the absence of spontaneous respirations: This is the priority action because the absence of spontaneous respirations may indicate inadequate ventilation or respiratory arrest, requiring immediate intervention.

C. Encourage the client to take spontaneous breaths: While encouraging spontaneous breaths is beneficial, it is not appropriate if the client is paralyzed due to neuromuscular blockade.

D. Place the call bell within reach: Ensuring the call bell is within reach is important for communication but may not be the priority if the client is not breathing spontaneously.

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A client presents to the emergency department seeking treatment for radiation burns. The nurse should develop the client's plan of care based on which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a chest tube in place for treatment of a hemothorax. The nurse should prioritize which nursing intervention when caring for this client?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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