A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following actions should the nurse take? (Select all that apply.)

Limit visitors to 30 min per day.

Instruct visitors who are pregnant to remain 3 feet from the client.

Wear a lead apron when providing care.

Place the client in a semi-private room.

Close the door to the client's room.

Answer and Explanation

Correct Answer : A,B,C,E

Rationale:

A. Limit visitors to 30 min per day: Time restrictions help minimize radiation exposure to visitors. Short visits reduce the cumulative dose received, which is especially important for non-staff individuals who are not regularly monitored for radiation exposure.

B. Instruct visitors who are pregnant to remain 3 feet from the client: Pregnant individuals should avoid close contact with radiation sources due to fetal sensitivity. Maintaining a 3-foot distance helps reduce exposure to scattered radiation from the sealed implant.

C. Wear a lead apron when providing care: A lead apron provides protection against scatter radiation, particularly during direct, prolonged care. Nurses should also stand as far away from the source as possible and work efficiently to limit time near the implant.

D. Place the client in a semi-private room: Clients with sealed radiation implants require a private room to protect others from radiation exposure. A semi-private room would place another patient at unnecessary risk and violates radiation safety protocols.

E. Close the door to the client's room: Keeping the door closed helps contain radiation within the room, thereby protecting other individuals in the surrounding area. It is a standard precaution for clients receiving internal radiation therapy.

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Correct Answer is ["B","D","E"]

Explanation

Rationale:

A. Polydipsia: Polydipsia, or excessive thirst, is commonly associated with hyperglycemia due to osmotic diuresis caused by high blood glucose levels. It is not a typical feature of hypoglycemia.

B. Tremors: Tremors are a hallmark symptom of hypoglycemia. They result from the body's adrenergic (sympathetic) response to low blood glucose levels, which triggers the release of epinephrine to raise glucose.

C. Acetone breath odor: A fruity or acetone breath odor is associated with diabetic ketoacidosis, a complication of hyperglycemia, not hypoglycemia. It indicates ketone buildup due to fat metabolism in the absence of insulin.

D. Inability to concentrate: Cognitive impairment, such as confusion or difficulty concentrating, is a neurological symptom of hypoglycemia. The brain relies heavily on glucose, and low levels affect its function quickly.

E. Diaphoresis: Sweating is a common autonomic symptom of hypoglycemia due to activation of the sympathetic nervous system. It often occurs early in a hypoglycemic episode and is a critical sign to monitor.

A. Collect 4 mL/kg of blood in a 24-hr period. B. Apply lidocaine cream 30 min prior to collecting the specimen. C. Ask the parents to leave the room prior to collecting the blood specimen. D. Demonstrate the use of the equipment to the child.

Correct Answer is D

Explanation

Rationale:

A. Collect 4 mL/kg of blood in a 24-hr period: This volume exceeds safe limits for blood collection in small children. The guideline is not to exceed 3 mL/kg over 24 hours unless clinically necessary, as excessive draws can lead to anemia or hemodynamic instability.

B. Apply lidocaine cream 30 min prior to collecting the specimen: While lidocaine-prilocaine cream can be helpful, it typically requires at least 60 minutes to achieve adequate dermal analgesia. Applying it for only 30 minutes may not be sufficient to reduce pain effectively.

C. Ask the parents to leave the room prior to collecting the blood specimen: Parents are often a source of comfort and reassurance for preschoolers. Unless their presence is disruptive, involving them in the process can help calm the child and improve cooperation.

D. Demonstrate the use of the equipment to the child: Preschoolers benefit from age-appropriate explanations and demonstrations. Showing them the equipment reduces fear and anxiety by promoting familiarity and a sense of control in an unfamiliar situation.

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A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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