A nurse is caring for a client who has a newly implanted sealed internal radiation device to treat cervical cancer. Which of the following is an appropriate action for the nurse to take?
Prohibit visitors for the first 24 hr.
Keep a 3-foot distance from the radiation implant.
Maintain the client on bed rest for 72 hr.
Require the client wear a dosimeter badge.
The Correct Answer is D
A. Prohibiting visitors is not necessary for clients with sealed internal radiation implants. Visitors should be allowed unless specific restrictions are required based on the type of radiation therapy.
B. While maintaining distance from the radiation source is important, there is no specific guideline stating a 3-foot distance. The nurse should follow institutional policies and radiation safety guidelines regarding proximity to the radiation source.
C. There is no need to maintain the client on bed rest for 72 hours after receiving a sealed
internal radiation device. The client should be encouraged to ambulate and perform activities of daily living as tolerated.
D. Requiring the client to wear a dosimeter badge allows healthcare providers to monitor the amount of radiation exposure received by the client and ensures that radiation safety protocols are followed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Inserting an indwelling catheter is within the scope of practice for an LPN and requires technical skill and training that an LPN possesses. This task is appropriate for delegation because it does not require the RN's direct clinical judgment or assessment at the time of insertion. The LPN can perform this procedure based on a specific directive from the RN.
B. Obtaining the abdominal girth is a task that involves assessment and this cannot be delegated by the RN to an LPN.
C. Assessing and documenting the level of consciousness involves critical thinking and
interpretation of assessment findings, making it more appropriate for the registered nurse to perform.
D. Measuring gastric drainage is a task that the LPN can perform, but it is less critical compared to the insertion of an indwelling catheter in this scenario. The RN should prioritize delegating tasks to the LPN that require their specific skills, such as catheter insertion, while reserving simpler tasks for the AP.
Correct Answer is B
Explanation
A. Vancomycin is not typically associated with hepatotoxicity.
B. Ototoxicity, which can manifest as hearing loss or tinnitus, is a potential adverse reaction of vancomycin therapy, especially with prolonged or high-dose therapy. Monitoring for signs of hearing impairment is essential.
C. Hypercalcemia is not a common adverse reaction associated with vancomycin therapy.
D. Hypertension is not a common adverse reaction associated with vancomycin therapy.
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