A nurse is planning care for a client who is receiving internal brachytherapy. Which of the following interventions should the nurse include in the plan of care?
Place the client in a negative pressure room.
Dispose of the radioactive source in the client's trash can.
Limit each visitor to 1 hr per day.
Use long-handled forceps if the radioactive source is dislodged.
The Correct Answer is D
A. Place the client in a negative pressure room: Negative pressure rooms are used for airborne precautions, such as tuberculosis, but are not required for internal brachytherapy. Clients receiving internal radiation require a private room with appropriate shielding to limit radiation exposure.
B. Dispose of the radioactive source in the client's trash can: Radioactive sources should never be discarded in regular trash. If dislodged, the source must be handled properly using protective equipment and disposed of in a designated lead container to prevent radiation exposure.
C. Limit each visitor to 1 hr per day: Visitors should be limited to 30 minutes per day and should maintain a distance of at least 6 feet from the client. This minimizes radiation exposure to family members and healthcare providers.
D. Use long-handled forceps if the radioactive source is dislodged: If the internal radiation source becomes dislodged, it should never be touched directly. Long-handled forceps should be used to carefully place the source in a lead-lined container to protect against radiation exposure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F"]
Explanation
- Tightness in chest that radiates to left arm: Classic symptom of acute coronary syndrome (ACS), including myocardial infarction (MI). Cardiac pain is often described as pressure, squeezing, or tightness and may radiate to the left arm, jaw, or back.
- Pain rated 7 on a scale of 0 to 10: Severe pain is a hallmark of an MI and suggests significant myocardial ischemia. Persistent or worsening chest pain should prompt urgent intervention.
- Nausea after breakfast: Nausea and gastrointestinal discomfort can be atypical signs of an MI, particularly in individuals with diabetes. The presence of nausea alongside chest pain raises suspicion for cardiac ischemia.
- Diaphoresis and shortness of breath: Sweating and dyspnea are common autonomic responses to myocardial ischemia. The body reacts to decreased cardiac output by activating the sympathetic nervous system, which results in these symptoms.
- Heart rate irregular and tachycardic: Irregular tachycardia suggests possible arrhythmias, which can be triggered by myocardial ischemia and infarction. Life-threatening dysrhythmias are a significant complication of an MI.
- Skin is cool to touch: Cool skin indicates decreased peripheral perfusion, which may result from reduced cardiac output due to myocardial dysfunction. It is a concerning sign of potential hemodynamic instability.
- Lungs clear to auscultation in all lobes: The absence of crackles or other abnormal lung sounds suggests that pulmonary congestion is not currently present.
- Bowel sounds are present in all 4 quadrants: Normal bowel sounds do not indicate any gastrointestinal pathology.
- +1 pedal pulses: Diminished pulses may suggest peripheral vascular disease but are not directly indicative of an acute cardiac event.
- Capillary refill less than 2 seconds: Normal capillary refill indicates adequate peripheral perfusion and does not suggest an immediate concern.
Correct Answer is ["C","D","E","F","G","H","I","J"]
Explanation
- Open wound on right foot with purulent drainage: A non-healing wound with purulent drainage suggests infection, which is a major concern in clients with hyperglycemia. Poor wound healing is common in diabetes due to impaired circulation and immune function.
- Frequent urination, increased thirst, and unexplained 4.5 kg (10 lb) weight loss: Classic symptoms of hyperglycemia and possible diabetes mellitus. Polyuria and polydipsia result from osmotic diuresis due to high blood glucose levels, while unexplained weight loss may indicate the body breaking down fat and muscle for energy.
- Temperature 38.3° C (100.9° F): Fever indicates a possible systemic infection. In diabetic clients, infections can progress rapidly and lead to complications such as cellulitis, osteomyelitis, or sepsis.
- Heart rate 104/min: Tachycardia may be a response to fever, dehydration, or underlying infection. Persistent tachycardia could indicate worsening sepsis or hemodynamic instability.
- Blood pressure 98/74 mm Hg: While not critically low, this blood pressure is on the lower end and could indicate early signs of dehydration from polyuria or systemic infection.
- Blood glucose 250 mg/dL: Significantly elevated blood glucose suggests poor glycemic control, increasing the risk of infection, delayed wound healing, and diabetic ketoacidosis (DKA) if it continues to rise.:
- Respiratory rate 18/min: A normal respiratory rate does not indicate respiratory distress or metabolic compensation.
- Oxygen saturation 97% on room air: Oxygenation is within the normal range, suggesting no immediate hypoxia.
- WBC count 9,500/mm³: Within the normal range, although an infection may still be present given the fever and purulent wound drainage.
- Triiodothyronine (T3) 200 mg/dL: Within normal limits, ruling out thyroid dysfunction as a cause of symptoms.
- BMI 27: Slightly overweight but not directly contributing to the acute condition.
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