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 A
Explanation
Log-rolling is a technique used to safely turn a client who requires immobilization of the spine or has limited mobility. After log-rolling the client to a lateral position, it is important to maintain proper alignment to prevent injury and promote comfort. Placing pillows strategically can help support and maintain the client's alignment in the lateral position.
The other options mentioned are not the immediate interventions following log-rolling:
B. Raising the head of the bed 30 degrees may be indicated for specific medical conditions or interventions, but it is not the immediate intervention after log-rolling.
C. Flexing the legs and placing a blanket between them is a positioning technique used for preventing skin breakdown and pressure ulcers, but it is not the immediate intervention after log-rolling.
D. Measuring the blood pressure and pulse rate is an important nursing assessment, but it is not the immediate intervention after log-rolling.
Correct Answer is D
Explanation
While caring for a client with Guillain-Barre syndrome, the practical nurse (PN) should report the finding of irregular heart rate to the charge nurse. Guillain-Barre syndrome is a neurological disorder that can affect multiple body systems, including the autonomic nervous system.
Autonomic dysfunction can lead to various cardiovascular abnormalities, such as changes in heart rate and rhythm.
However, irregular heart rate can indicate potential cardiac involvement or autonomic instability, which requires prompt evaluation and intervention. Therefore, the PN should report the finding of an irregular heart rate to the charge nurse for further assessment and appropriate management.
Incorrect:
A, B- Full facial flushing and profuse diaphoresis are common symptoms that can occur in Guillain-Barre syndrome due to autonomic dysfunction. While these findings should be noted and monitored, they may not require immediate reporting unless they are severe or accompanied by other concerning symptoms.
C- Lower leg weakness is a characteristic symptom of Guillain-Barre syndrome and is expected in this condition. The PN should document and monitor the extent and progression of weakness but does not necessarily need to report it unless there are significant changes or complications.
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