A nurse is caring for a client who has a sealed radiation implant. Which of the following actions should the nurse take?
Give the dosimeter badge to the oncoming nurse at the end of the shift.
Limit family member visits to 30 min per day.
Remove soiled linens from the room after each change.
Apply a second pair of gloves before touching the client's implant if it dislodges.
The Correct Answer is B
B. Family visits should be limited to 30 minutes per day to minimize their exposure.
A It should be worn consistently by the nurse caring for the client with the radiation implant to monitor their radiation exposure. Giving it to the oncoming nurse at the end of the shift is not appropriate because it does not provide real-time monitoring of radiation exposure for the nurse during their shift.
C. Soiled linens should be kept in the room until the radioactive source is removed to prevent the spread of contamination
D. One should never touch it directly; instead, use long-handled forceps and place it in a lead-lined container for safe disposal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
The client is at highest risk for wound infection as evidenced by the blood glucose level
Rationale
Type 2 diabetes mellitus: The client has poorly controlled diabetes with a preoperative Hemoglobin A1C of 9.5% and elevated glucose levels (280 mg/dL currently). Elevated blood glucose levels impair immune function and increase the risk of surgical site infections, including wound infections.
Postoperative state: After total knee arthroplasty, surgical wounds are vulnerable to infection. Hyperglycemia (high blood glucose levels) further increases susceptibility to infections due to impaired wound healing and compromised immune response.
Evidence: The client's current blood glucose level of 280 mg/dL (normal range 74 to 106 mg/dL) indicates poor glycemic control, which is a significant risk factor for developing wound infections postoperatively.
Correct Answer is B
Explanation
B. This is often the nurse's top priority in the PACU. Anesthesia can depress respiratory function, leading to hypoventilation or airway obstruction. The nurse assesses respiratory rate, effort, oxygen saturation, and auscultates breath sounds to ensure adequate ventilation. Addressing any respiratory compromise promptly is crucial to prevent hypoxia or respiratory arrest.
A Assessing the surgical site is important to monitor for bleeding, infection, or any other complications related to the procedure. However, immediately after surgery, other assessments take precedence over this unless there is a specific concern like excessive bleeding or signs of infection.
C. Monitoring the client's level of consciousness is vital to detect any signs of neurological complications or delayed emergence from anesthesia. The nurse assesses orientation, responsiveness, and neurological signs to ensure the client is awakening appropriately from anesthesia.
D. Assessing pain is important as clients may experience discomfort after surgery. Pain can also affect respiratory function and overall recovery. However, it is typically assessed after ensuring respiratory status and consciousness are stable, as uncontrolled pain can be managed once immediate physiological concerns are addressed.
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