A nurse is caring for a 66-year-old client who has a new diagnosis of lung cancer.

Exhibits

For each potential healthcare provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.

Place the client on droplet precautions.

Insert an indwelling urinary catheter.

Place the client in a private room

Check the client's rectal temperature once daily.

Rinse the client's mouth with 0.9% sodium chloride every 4 hours

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Placing the client on droplet precautions is anticipated as it is a standard practice to prevent infection, especially in immunocompromised patients like those undergoing chemotherapy.

A private room is also anticipated to reduce the risk of infection and provide a controlled environment for the patient's comfort and monitoring.

The insertion of an indwelling urinary catheter may be nonessential unless there is a specific indication, such as urinary retention or close monitoring of output in a critically ill patient, as it can increase the risk of urinary tract infections.

Checking the client's rectal temperature once daily could be contraindicated due to the risk of causing trauma or bleeding, especially considering the client's decreased platelet count, which could lead to increased bleeding risk.

Lastly, rinsing the client's mouth with 0.9% sodium chloride every 4 hours is anticipated to help manage the sore mouth, a common side effect of chemotherapy, and to maintain oral hygiene, which is crucial in preventing infections in immunocompromised patients.

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Correct Answer is A

Explanation

A. The first priority in this situation is to open the client's airway using the jaw-thrust maneuver. This technique is preferred for clients with suspected spinal injuries to avoid further spinal cord damage. Ensuring the airway is open and providing oxygenation are immediate life-saving actions.
B. Checking cranial nerve function, including assessing pupils, is important for evaluating neurological status but is not the first action when the client is not breathing. Ensuring the airway is open and providing oxygenation is the priority.
C. While placing the client in a rigid cervical collar is important for stabilizing the spine and preventing further injury, it should be done after ensuring the airway is clear. The immediate concern is to address the client's non-breathing status.
D. Evaluating the client for brain injury is important for overall assessment but is secondary to addressing the immediate life threat of not breathing. Ensuring the airway is open and then stabilizing the spine is the priority.

A. The client should avoid crowded places. B. The client should avoid eating fresh fruits and vegetables. C. The client should maintain at least 6 feet from any visitors. D. The client should avoid washing off the radiation tattoo markings.

Correct Answer is C

Explanation

A. Avoiding crowded places is a precaution related to general health and infection control but is not specifically linked to internal radiation therapy.
B. Avoiding fresh fruits and vegetables is not required for internal radiation therapy. Dietary restrictions are not typically necessary unless specified by the healthcare provider.
C. For internal radiation therapy, maintaining distance from others, typically around 6 feet, is important to minimize radiation exposure to others. This safety measure helps reduce the risk of radiation exposure to family members and visitors.
D. Radiation tattoo markings are used to ensure proper placement of the radiation source and should not be washed off. However, this precaution does not directly relate to safety around radiation exposure.

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A nurse is caring for a 66-year-old client who has a new diagnosis of lung cancer. Exhibits For each potential healthcare provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.

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Explanation

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A nurse is caring for a 66-year-old client who has a new diagnosis of lung cancer.

Exhibits

For each potential healthcare provider's prescription at 4 weeks, click to specify if the prescription is anticipated, nonessential, or contraindicated for the client.