A client with uterine cancer is being treated with internal radiation herapy (brachytherapy). What is the nurse's PRIORITY action when caring for this client?

Wear a dosimeter badge and lead apron when providing direct patient care.

Avoid placing a radiation sign at the entrance of the room for patient privacy

Alert family members that they should restrict their visiting to 60 minutes at a time.

Explain to the patient that she will continue to emit radiation for months after the implant is removed.

Answer and Explanation

The Correct Answer is A

A) Wear a dosimeter badge and lead apron when providing direct patient care: When caring for a patient undergoing internal radiation therapy (brachytherapy), radiation safety is the nurse’s priority. The nurse must take measures to minimize radiation exposure by wearing protective equipment such as a dosimeter badge (to monitor exposure levels) and a lead apron (to shield against radiation). These precautions are critical to protect healthcare workers from potential radiation harm while caring for a patient with a radiation implant.

B) Avoid placing a radiation sign at the entrance of the room for patient privacy: Placing a radiation warning sign at the entrance of the room is a mandatory safety protocol when a patient is undergoing brachytherapy. This warning sign informs healthcare personnel and visitors that radiation is present, and it is important for ensuring safety. Patient privacy should not override radiation safety protocols.

C) Alert family members that they should restrict their visiting to 60 minutes at a time: While it is essential to inform family members about safety precautions when visiting a patient receiving radiation therapy, the priority action for the nurse is to ensure their own safety and radiation exposure first. Limiting family visits is an important step to reduce unnecessary exposure, but this is a secondary concern compared to the nurse's direct radiation safety measures.

D) Explain to the patient that she will continue to emit radiation for months after the implant is removed: The patient will continue emitting radiation only for a short period after the implant is removed. The duration of radiation emission depends on the type of radioactive material used in brachytherapy, but it is typically limited to a few days or weeks at most. In most cases, the nurse would explain to the patient that, after the implant is removed, radiation emission will cease.

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Correct Answer is C

Explanation

A) Normal saline 1 liter to client who is dehydrated:
Administering normal saline to a dehydrated client is an important task, as it helps to restore fluid balance and improve circulatory volume. However, while rehydration is critical, it is not an immediate, life-threatening priority compared to other interventions. The nurse should begin this infusion after addressing more urgent needs such as severe chest pain, which could indicate a cardiac emergency.

B) Morphine sulfate 4mg intravenously (IV) now for the client experiencing incisional pain:
Morphine is a potent analgesic, and relieving pain for postoperative patients is essential for comfort and recovery. However, incisional pain, although important to address, is not life-threatening in this scenario. The client with chest pain should be prioritized because chest pain could indicate a myocardial infarction (MI) or other serious cardiac event that requires immediate intervention.

C) Nitroglycerin (Nitrostat) 0.4 mg sublingually (SL) stat for the client experiencing crushing chest pain:
Crushing chest pain is a classic symptom of acute myocardial infarction (MI), a life-threatening condition that requires immediate intervention. Nitroglycerin is used to relieve chest pain associated with angina or MI by dilating the coronary arteries and improving blood flow to the heart. In this case, chest pain is the most critical symptom, and immediate treatment is necessary to reduce the risk of further cardiac damage or complications.

D) Lorazepam 2 mg IV now for the client who is anxious and restless:
While lorazepam is an effective medication for anxiety and restlessness, it is not the most urgent medication in this case. The client’s anxiety should be addressed, but it does not pose an immediate threat to life. Anxiety can generally be managed after more acute, life-threatening conditions (such as chest pain) are stabilized.

A. Crackles upon auscultation B. Palpable liver during assessment C. Pitting Edema D. Distended jugular veins

Correct Answer is A

Explanation

A) Crackles upon auscultation:
Left-sided heart failure occurs when the left ventricle is unable to effectively pump blood to the body, causing blood to back up into the lungs. This results in pulmonary congestion, which often manifests as crackles (also called rales) upon auscultation, particularly in the lower lobes of the lungs. The crackles are caused by the fluid accumulation in the alveoli, a hallmark sign of left-sided heart failure.

B) Palpable liver during assessment:
A palpable liver is more commonly associated with right-sided heart failure. In right-sided heart failure, the blood backs up into the venous system, causing congestion in organs such as the liver and spleen. This leads to hepatomegaly (enlargement of the liver), which can be palpated during physical examination. Therefore, a palpable liver is not typically a manifestation of left-sided heart failure.

C) Pitting Edema:
Pitting edema is more characteristic of right-sided heart failure. When the right ventricle is unable to pump blood effectively, blood backs up in the systemic circulation, leading to fluid retention and edema in the lower extremities, abdomen (ascites), or other dependent areas. While pitting edema can occur in left-sided heart failure, it is more commonly a finding in right-sided heart failure or congestive heart failure.

D) Distended jugular veins:
Distended jugular veins (JVD) are also a sign of right-sided heart failure, not left-sided heart failure. When the right side of the heart fails, blood backs up in the venous system, leading to increased venous pressure, which can be observed as jugular venous distension. This is a key finding in right-sided heart failure.

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A client with uterine cancer is being treated with internal radiation herapy (brachytherapy). What is the nurse's PRIORITY action when caring for this client?

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