A nurse is planning care for a client who is receiving brachytherapy. Which of the following interventions should the nurse include in the plan of care?

Dispose of the client's feces and urine in a special container.

Instruct visitors to limit the visit to 60 min each day.

Keep the client's linens in the room until after removal of the radiation source.

Keep one dosimeter badge available for the staff to share while caring for the client.

Answer and Explanation

The Correct Answer is A

Dispose of the client's feces and urine in a special container.

Choice A rationale:

This is the correct choice. Brachytherapy involves the placement of a radiation source in or near the tumor. To minimize radiation exposure to others, the client's bodily fluids (feces and urine) should be considered radioactive and disposed of properly in a designated container.

Choice B rationale:

While limiting the time of visitors can be a good measure to reduce radiation exposure, it is not the priority intervention. The primary concern is proper handling and disposal of radioactive bodily fluids.

Choice C rationale:

Keeping the client's linens in the room until after removal of the radiation source is not the correct choice. Radioactive linens should be handled and laundered separately, following appropriate safety protocols.

Choice D rationale:

Providing one dosimeter badge for staff to share while caring for the client is not adequate. Each staff member involved in direct care should have their dosimeter badge to monitor their individual radiation exposure levels.

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Correct Answer is B

Explanation

Choice A rationale:
An elevated WBC count (11,000/mm²) in a client starting treatment for MRSA infection may indicate an inflammatory response, but it is expected in this scenario, and the priority is not as high as other critical lab values.
Choice B rationale:
A serum pH of 7.25 indicates acidosis, which is a potentially life-threatening condition. In type 1 diabetes mellitus, diabetic ketoacidosis (DKA) is a common complication that can lead to metabolic acidosis. This lab result is a priority as it requires immediate attention.
Choice C rationale:
Hematocrit of 26% in a client with sickle cell disease might be low, but it is not the priority over the critically abnormal lab value of serum pH in option B.
Choice D rationale:
A urine specific gravity of 1.032 in a client diagnosed with dehydration is elevated, indicating concentrated urine due to dehydration. While dehydration is concerning, it is not as high-priority as the potentially life-threatening acidosis in option B.

A. Wear a protective gown when suctioning the client's airway. B. Monitor for oral secretions every 2 hr. C. Provide oral care every 2 hr. D. Maintain the client in a supine position. E. Assess the client daily for readiness of extubation.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale:

The nurse should wear a protective gown when suctioning the client's airway to prevent the spread of infection. During suctioning, there is a risk of exposure to the client's respiratory secretions, which may contain infectious organisms. Wearing a gown will help protect the nurse from contact with these secretions.

Choice B rationale:

Monitoring for oral secretions every 2 hours is essential to prevent the accumulation of mucus or saliva in the client's mouth. Excessive secretions can increase the risk of aspiration, which may lead to ventilator-associated pneumonia (VAP).

Choice C rationale:

Providing oral care every 2 hours is crucial to maintain oral hygiene and reduce the growth of bacteria in the mouth. Oral bacteria can potentially enter the lungs during mechanical ventilation, contributing to the development of VAP.

Choice D rationale:

Maintaining the client in a supine position is not recommended as it can increase the risk of VAP. The supine position may cause secretions to pool in the back of the throat, making it more likely for the client to aspirate these secretions.

Choice E rationale:

Assessing the client daily for readiness for extubation is important but not directly related to decreasing the risk of VAP. Extubation refers to the removal of the endotracheal tube, which helps prevent complications associated with prolonged intubation but does not specifically address VAP prevention.

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A nurse is planning care for a client who is receiving brachytherapy. Which of the following interventions should the nurse include in the plan of care?

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