A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care?

Limit each of the client's visitors to 1 hr per day.

Remove dirty linens from the room after double bagging.

Wear a dosimeter film badge while in the client's room.

Ensure family members remain at least 1 m (3.2 feet) from the client.

Answer and Explanation

The Correct Answer is C

A. Limit each of the client's visitors to 1 hr per day. - This is not necessary specifically due to the presence of the radiation implant. Visitation restrictions should be based on hospital policy and

the client's condition, not solely on the presence of a radiation implant.

B. Remove dirty linens from the room after double bagging. - This is a standard infection control measure and is not specific to caring for a client with a radiation implant.

C. Wear a dosimeter film badge while in the client's room. - Healthcare workers who care for clients with sealed radiation implants should wear dosimeter film badges to monitor their radiation exposure levels.

D. Ensure family members remain at least 1 m (3.2 feet) from the client. - While limiting exposure to radiation is important, maintaining distance alone may not provide adequate

protection. Healthcare workers should follow appropriate safety precautions and use shielding as necessary when caring for clients with radiation implants.

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Correct Answer is A

Explanation

A. Inserting an indwelling catheter is within the scope of practice for an LPN and requires technical skill and training that an LPN possesses. This task is appropriate for delegation because it does not require the RN's direct clinical judgment or assessment at the time of insertion. The LPN can perform this procedure based on a specific directive from the RN.
B. Obtaining the abdominal girth is a task that involves assessment and this cannot be delegated by the RN to an LPN.

C. Assessing and documenting the level of consciousness involves critical thinking and

interpretation of assessment findings, making it more appropriate for the registered nurse to perform.

D. Measuring gastric drainage is a task that the LPN can perform, but it is less critical compared to the insertion of an indwelling catheter in this scenario. The RN should prioritize delegating tasks to the LPN that require their specific skills, such as catheter insertion, while reserving simpler tasks for the AP.

A. "Report the incident to Adult Protective Services." B. "Interview the client with his adult child present." C. "Tell the client he must answer every assessment question." D. "Advise the client to consult a social worker."

Correct Answer is A

Explanation

A. "Reporting the incident to Adult Protective Services" is crucial when there are signs of elder abuse or neglect. This action ensures that appropriate interventions are initiated to protect the client.

B. "Interviewing the client with his adult child present" may not allow the client to speak freely, especially if the adult child is the perpetrator or involved in the abuse. Confidentiality and safety are essential considerations.

C. "Telling the client he must answer every assessment question" can be intimidating and may not facilitate open communication, especially in situations involving abuse.

D. "Advising the client to consult a social worker" may be appropriate after reporting the incident to Adult Protective Services, but it is not the initial action to take when abuse is suspected. Reporting to authorities is the priority to ensure the client's safety.

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A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care?

Nursing Test Bank

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