A client who has four gold seed implants on a chest wall tumor is on radiation precautions. What basic precautions should the practical nurse (PN) observe when administering direct care to this client?
Minimal time, maximum distance, and protective shielding.
Rotate the assignment with other staff during the shift.
Virtual observation and wearing a film badge for exposure.
Standard precautions with negative pressure isolation.
The Correct Answer is A
The practical nurse (PN) should observe minimal time, maximum distance, and protective shielding when administering direct care to a client who has four gold seed implants on a chest wall tumor.
Minimal time refers to limiting the duration of direct exposure to the client with the gold seed implants. This helps minimize the nurse's exposure to radiation.
Maximum distance refers to maintaining a safe distance from the client with the gold seed implants. The nurse should try to stay as far away as possible while still being able to provide necessary care.
Protective shielding involves using lead aprons, gloves, and other appropriate shielding materials to protect oneself from radiation exposure. These protective measures help reduce the nurse's exposure to radiation during care activities.
B. Rotating assignments with other staff during the shift may not be necessary in this situation unless there are specific staffing requirements or guidelines in place. The primary focus should be on minimizing the nurse's exposure to radiation through time, distance, and shielding.
C. Virtual observation and wearing a film badge for exposure are not applicable in this context. These measures are more relevant for monitoring radiation exposure over time and do not directly address the precautions needed during direct care.
D. Standard precautions with negative pressure isolation are not specifically indicated for a client with gold seed implants. Negative pressure isolation is typically used for clients with infectious diseases that require airborne precautions, and it is not directly related to radiation precautions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Croup is a viral infection that affects the upper airways, causing inflammation and narrowing of the air passages. In severe cases, it can lead to respiratory distress, including increased work of breathing and decreased oxygen saturation levels. Monitoring the child's oxygen saturation level using a pulse oximeter is an essential intervention to assess the severity of respiratory distress and the need for further interventions.
A. Encouraging the child to drink cool, clear liquids can help soothe the throat and prevent dehydration.
B. Instructing the mother to play with the child for stimulation and distraction can help provide comfort and alleviate anxiety.
D. Administering acetaminophen as needed (PRN) can help reduce fever and discomfort. However, none of these interventions directly address the potential respiratory distress and the need for oxygenation assessment.
Correct Answer is ["C","E","F"]
Explanation
C.Place pillows around the bed rails to provide padding: During a tonic-clonic seizure, the client may experience uncontrolled movements and convulsions. Placing pillows around the bed rails helps prevent injury by providing padding and cushioning.
E.Increase the supplemental oxygen to 10 L/min via nasal cannula: The client's oxygen saturation is dangerously low at 40%. Increasing the supplemental oxygen to 10 L/min via nasal cannula will help improve oxygenation and prevent hypoxia.
F.Manually ventilate the client with a bag-valve-mask: Since the respiratory rate is only 4 breaths/min, the client is not adequately ventilating on their own. Manual ventilation with a bag-valve maskwill provide necessary oxygenation and ventilation support during the seizure.
The other options are not appropriate actions at this time:
- Begin chest compressions: Chest compressions are indicated if the client's heart has stopped or if they are in cardiac arrest. Since the scenario describes a seizure, the client's heart is presumed to be functioning.
- Watch the seizure activity and document the time and client movement: Although documentation is important, during an active seizure, the priority is to ensure the client's safety and provide immediate interventions. Documentation can be done after the seizure has ended.
- Stop the IV fluids: There is no indication to stop the IV fluids based on the given information. IV fluids are generally continued unless there is a specific reason to discontinue them.
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