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,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

Explanation

Rationale:

A. Disconnecting the catheter from the drainage bag to empty the bag: This increases the risk of introducing pathogens into the closed urinary drainage system, leading to potential catheter-associated urinary tract infections (CAUTIs). The drainage bag should be emptied without breaking the system.

B. Emptying the drainage bag when it is half full: This prevents backflow of urine, which could lead to infection or increased bladder pressure. Regular emptying also allows for accurate measurement of urine output and maintains client comfort.

C. Keeping the drainage bag above waist level: Elevating the bag above the bladder increases the risk of backflow of urine into the bladder, which can introduce bacteria and cause infection. The bag should always remain below the level of the bladder.

D. Using sterile gloves when emptying the drainage bag: Sterile gloves are not necessary for this procedure. Clean gloves are sufficient since the nurse or AP is not entering the sterile parts of the urinary system but rather emptying the bag from the outlet port.

A. Take mineral oil at bedtime. B. Decrease insoluble fiber intake. C. Increase exercise activity. D. Drink 1.5 L of fluids each day.

Correct Answer is C

Explanation

Rationale:

A. Take mineral oil at bedtime: Mineral oil is not recommended for long-term use because it can interfere with absorption of fat-soluble vitamins and may lead to aspiration pneumonia, especially in older adults. Safer stool softeners or laxatives should be used for opioid-induced constipation.

B. Decrease insoluble fiber intake: Insoluble fiber, such as wheat bran, helps bulk the stool and promote bowel movements. Reducing fiber intake can worsen constipation rather than relieve it, especially in clients taking opioids.

C. Increase exercise activity: Regular physical activity stimulates peristalsis and helps prevent constipation. Movement is a key non-pharmacologic strategy to counteract the slowed gastrointestinal motility caused by opioids.

D. Drink 1.5 L of fluids each day: Although hydration is important, adults typically require around 2 to 3 liters of fluid daily unless contraindicated. Limiting intake to 1.5 L may be insufficient to support normal bowel function and soften stool.

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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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