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 C

Explanation

Rationale:

A. Palpate the client's bladder in 1 hour: Waiting another hour to assess the bladder delays intervention. At 10 hours postpartum with no void, immediate action is needed to stimulate voiding or assess for urinary retention.

B. Place the client's hands in a bowl of cold water: This technique is more commonly used in children and is less effective in stimulating voiding in postpartum adults. It is not a first-line strategy in this context.

C. Have the client listen to running water while on the toilet: This is a noninvasive and effective method to stimulate the urge to void by triggering the micturition reflex. It can help relax pelvic muscles and encourage urination postpartum.

D. Perform effleurage over the client's lower abdomen: Effleurage is a light massage technique used primarily for labor pain management. It is not a recognized or effective method to promote urination in postpartum care.

A. The nurse positions a client who is postoperative in a semi-Fowler's position. B. The nurse performs auscultation of the lungs without lifting the gown. C. The nurse applies a cold compress to reduce localized swelling. D. The nurse uses clean gloves when administering an enema

Correct Answer is B

Explanation

Rationale:

A. The nurse positions a client who is postoperative in a semi-Fowler's position: Semi-Fowler's position is commonly used postoperatively to promote lung expansion, prevent aspiration, and support comfort. This is an appropriate nursing action that does not require correction.

B. The nurse performs auscultation of the lungs without lifting the gown: Lung auscultation should always be performed on bare skin to ensure accurate assessment of breath sounds. Clothing can muffle or distort the sounds, potentially leading to misinterpretation or missed abnormalities.

C. The nurse applies a cold compress to reduce localized swelling: Cold therapy is appropriate for managing inflammation, bruising, or swelling in many clinical settings. This demonstrates correct therapeutic intervention and does not indicate a need for further instruction.

D. The nurse uses clean gloves when administering an enema: Clean (non-sterile) gloves are appropriate for enema administration since it is a non-sterile procedure. This action follows standard precautions and is acceptable for routine nursing care.

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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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