A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make?

Rationale:

A. Wear a dosimeter film badge to measure exposure: A dosimeter badge tracks the cumulative radiation exposure for healthcare workers. It is essential for staff safety when caring for clients with internal radiation therapy.

B. Discard bed linens from the client's room at the end of each day: Linens should not be discarded unless contaminated. They are usually kept in the room until radiation is removed to avoid unnecessary exposure to other staff or areas.

C. Instruct visitors to remain 61 cm (2 feet) away from the client: Visitors should maintain a greater distance typically at least 6 feet (about 2 meters) and limit their visit time (usually to 30 minutes or less). Two feet is insufficient to minimize radiation exposure.

D. Place a caution sign on the client's door: Posting a radiation warning sign helps alert all personnel and visitors about radiation precautions, promoting safety and compliance with guidelines.

E. Don a lead apron when providing care: A lead apron protects the nurse from radiation exposure, especially when prolonged or close contact is necessary. It is a critical part of personal protective equipment in this setting.

Rationale for Correct Choices:

• Antibiotic prescription: The client is showing signs of a possible postoperative wound infection (fever, elevated WBC count, purulent discharge, tenderness), all of which warrant initiation of antibiotics to control local and systemic infection.
• WBC count: The WBC has increased significantly from 8,000/mm³ on day 1 to 14,800/mm³ by day 3, indicating a developing infectious or inflammatory process likely related to the surgical site.
• Temperature: The temperature has risen to 38.8°C (101.8°F) by day 3, suggesting a febrile response to infection, which aligns with the findings of purulent wound drainage and local tenderness.

Rationale for Incorrect Choices:

• Laxative: Although the client hasn’t had a bowel movement, this is expected early in the postoperative period, especially with hypoactive bowel sounds. Laxatives are contraindicated until full bowel function returns.
• IV fluids: There is no evidence of fluid volume deficit skin turgor is normal, and vital signs are stable making IV fluids unnecessary at this time.
• Prescription for IV iron: While hemoglobin is low, there is no evidence of acute blood loss, and infection is the more urgent concern. Iron supplementation would be a longer-term consideration.
• Bowel sounds: Hypoactive bowel sounds are common after abdominal surgery and not in themselves a reason to start antibiotics.
• Blood pressure: Client's BP is stable and within acceptable range; it does not indicate infection or require antibiotic treatment.
• Skin turgor: Normal skin turgor suggests hydration is adequate, not an indication for antibiotic use.
• Transferrin level: While slightly decreased, this is a nonspecific finding and not indicative of acute infection or requiring antibiotics.
• Bowel movements: Absence of bowel movement alone post-surgery does not justify antibiotics; infection indicators are more critical.