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 D
Explanation
The vital sign trends that indicate increased intracranial pressure (ICP) and should be reported to the charge nurse are:
Bradycardia: A slow heart rate can be a sign of increased ICP.
Irregular respiratory patterns: Abnormal breathing patterns, such as irregular or Cheyne-Stokes respirations, can be indicative of increased ICP.
Widening pulse pressure: An increased difference between systolic and diastolic blood pressure (widening pulse pressure) can be a sign of increased ICP.
A- Heart rate above 110 beats/minute, elevated respiratory rate, and hypotension: While an elevated heart rate and respiratory rate can be associated with increased ICP, hypotension (low blood pressure) is not typically seen in this condition. Hypotension can be a sign of other factors, such as hypovolemia or shock, which may or may not be related to the head injury.
B- Bounding pulse rate, groaning respiratory effort, and elevated blood pressure: Bounding pulse rate and elevated blood pressure are not specific to increased ICP. They can be influenced by other factors such as pain, anxiety, or medications. Groaning respiratory effort may indicate respiratory distress, but it is not directly related to increased ICP.
C- Thready rapid pulse, trembling, perspiration, weakness, and irritability: These signs and symptoms can be associated with various conditions such as anxiety, stress, or other physiological responses. While they may occur in the context of increased ICP, they are not specific to this condition alone.
Correct Answer is A
Explanation
A. Gather the procedure tray and equipment – The practical nurse should gather all necessary supplies for the healthcare provider to perform the thoracentesis efficiently. Preparing the equipment beforehand ensures that the procedure can start promptly and reduces interruptions for missing supplies.
Rationale for Incorrect Answers:
B. Cleanse the site and cover with a sterile towel – This action should be performed by the healthcare provider immediately before the procedure to maintain sterility. The PN’s role is to prepare equipment and ensure the client is positioned correctly.
C. Keep the patient NPO (nothing by mouth) and encourage them to void – While voiding may be encouraged before some procedures to improve client comfort, it is not necessary for thoracentesis. Additionally, keeping the client NPO is not required, as the procedure does not typically involve sedation that would necessitate this restriction.
D. Place the patient in an orthopneic position – This may be done just before the procedure, but the healthcare provider typically directs the final positioning. Initial positioning or seating at the bedside can be done, but orthopneic positioning should follow the provider’s instructions.
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