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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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:

A. Pain level of 1 on a scale of 0 to 10: A low pain score suggests effective pain management and is not associated with poor wound healing. In fact, well-controlled pain can facilitate mobility and participation in recovery activities, both of which support healing.

B. Capillary refill time 1 second: This finding reflects good peripheral perfusion, indicating adequate circulation and oxygen delivery to tissues, which are essential for optimal wound healing.

C. BMI 35: A BMI of 35 indicates obesity, which is a known risk factor for delayed wound healing. Excess adipose tissue reduces vascularity, increases tension on wound edges, and raises the risk of infection and dehiscence.

D. Oxygen saturation 97% on room air: Normal oxygen saturation ensures tissues are receiving sufficient oxygen to support cellular repair and regeneration. This value supports wound healing rather than delaying it.

A. Increased platelet count B. Increased protein in urine C. Decreased BUN D. Decreased serum uric acid

Correct Answer is B

Explanation

Rationale:

A. Increased platelet count: Preeclampsia is often associated with thrombocytopenia (low platelet count), not an increase. A falling platelet count can be a warning sign of worsening disease or progression to HELLP syndrome.

B. Increased protein in urine: Proteinuria is one of the hallmark signs of preeclampsia, resulting from glomerular damage in the kidneys. A 24-hour urine protein test or dipstick is commonly used to detect elevated protein levels during pregnancy.

C. Decreased BUN: Blood urea nitrogen (BUN) may increase if renal perfusion is compromised, but a decrease is not typical in preeclampsia. Kidney involvement often leads to elevated BUN and creatinine levels.

D. Decreased serum uric acid: Preeclampsia usually causes elevated serum uric acid levels due to decreased renal clearance. A drop in uric acid would be inconsistent with this diagnosis

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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.)

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