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.
Correct Answer : A,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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Place a warm pack on the incisional area: Applying a warm pack immediately postoperatively can increase blood flow and risk bleeding or swelling at the surgical site. Cold packs are generally preferred in the immediate postoperative period to reduce inflammation.
B. Restrict fluids to 1,200 mL per day: Fluid restriction is not indicated after hernia repair unless the client has a comorbid condition like heart or renal failure. Adequate hydration supports healing and normal bowel and urinary function.
C. Elevate the client's scrotum on a pillow: Elevating the scrotum helps reduce swelling and discomfort after hernia repair, especially if the inguinal area is involved. This intervention promotes venous return and prevents complications like hematoma formation.
D. Encourage the client to sit to void: Sitting to void is not routinely necessary after hernia repair unless the client has mobility issues. There’s no specific benefit to this position in a typical male postoperative client.
Correct Answer is D
Explanation
Rationale:
A. “Dehydration is treated with calcium supplements.": Calcium supplementation is not a standard treatment for dehydration. Dehydration is primarily managed with fluid replacement, either orally or intravenously, depending on severity.
B. "Dehydration is caused by a decreased hemoglobin and hematocrit.": Dehydration often causes increased hemoglobin and hematocrit levels due to hemoconcentration, not a decrease. These lab values are used to assess hydration status but do not cause dehydration.
C. "Dehydration is associated with gastroesophageal reflux”: GERD is not a direct cause or result of dehydration. While fluid intake can influence GI symptoms, GERD and dehydration are unrelated conditions with different pathophysiologies.
D. "Dehydration can increase the risk for preterm labor”: Dehydration can trigger the release of antidiuretic hormone and oxytocin, both of which may lead to uterine contractions. It is a recognized risk factor for preterm labor and should be addressed promptly.
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