A nurse is contributing to the plan of care for a client who has cancer and is scheduled to receive internal radiation therapy. Which of the following actions should the nurse recommend?

Place the client in a private room

Secure a dosimeter badge to the client's gown

Don a cover gown before entering the client's room

Dispose of dislodged implants in a biohazard sharps container

Answer and Explanation

Correct Answer : A,C,D

Choice A reason: Placing the client in a private room is a correct action, because it reduces the exposure of other clients and staff to the radiation source.

Choice B reason: Securing a dosimeter badge to the client's gown is an incorrect action, because the dosimeter badge is used to measure the radiation exposure of the staff, not the client. The client should wear an identification bracelet that indicates the type and location of the radiation source.

Choice C reason: Donning a cover gown before entering the client's room is a correct action, because it protects the nurse's clothing from contamination by the client's body fluids or secretions.

Choice D reason: Disposing of dislodged implants in a biohazard sharps container is a correct action, because it prevents the spread of radiation and infection. The nurse should also notify the radiation safety officer if an implant is dislodged.

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Correct Answer is B

Explanation

Choice A reason: This is an incorrect action, because elevating the residual limb on a soft pillow can cause contractures and impair the blood flow to the stump. The residual limb should be elevated only for the first 24 hr after surgery, and then positioned flat on the bed.

Choice B reason: This is the correct action, because assisting the client to a prone position every 4 hr can prevent hip flexion contractures and promote the range of motion of the hip joint. The client should lie prone for 20 to 30 minutes at a time, with the residual limb extended.

Choice C reason: This is an incorrect action, because reapplying a bandage to the residual limb every 12 hr can increase the risk of infection and delay the healing of the wound. The bandage should be changed only when it is soiled or loose, and under sterile technique.

Choice D reason: This is an incorrect action, because applying dressings to the site in a proximal-to-distal direction can cause edema and impair the circulation to

A. Irrigate the catheter with sterile water B. Clamp the drainage catheter during ambulation C. Report viscous drainage with clots to the provider D. Remove the catheter if the client feels a strong urge to urinate

Correct Answer is C

Explanation

Choice A reason: Irrigating the catheter with sterile water is an incorrect action, because the catheter should be irrigated with sterile normal saline (0.9% sodium chloride) to prevent hemolysis of the red blood cells.

Choice B reason: Clamping the drainage catheter during ambulation is an incorrect action, because the catheter should be kept patent and unclamped at all times to prevent obstruction and infection.

Choice C reason: Reporting viscous drainage with clots to the provider is a correct action, because it indicates that the irrigation is not effective and the client may need manual irrigation or surgical intervention.

Choice D reason: Removing the catheter if the client feels a strong urge to urinate is an incorrect action, because the catheter should be left in place until the provider orders its removal. The client may feel a sensation of bladder fullness or spasms due to the irrigation fluid, which can be relieved by medication or adjustment of the flow rate.

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A nurse is contributing to the plan of care for a client who has cancer and is scheduled to receive internal radiation therapy. Which of the following actions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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