A nurse is planning care for a client who is undergoing brachytherapy with a low-dose radiation implant for treatment of prostate cancer.
Which of the following interventions should the nurse include in the client's plan of care?
Limit each of the client's visitors to 2 hr per day.
Instruct visitors to stay 1 m (3.3 feet) away from the client.
Attach a dosimeter to the client's gown.
Strain the client's urine.
The Correct Answer is C
Choice A rationale:
Limiting each of the client's visitors to 2 hours per day is not a necessary precaution for a client undergoing brachytherapy with a low-dose radiation implant. The duration of visitor stays does not directly impact the effectiveness of the treatment or the safety of the client.
Choice B rationale:
Instructing visitors to stay 1 m (3.3 feet) away from the client is not a standard practice for patients undergoing brachytherapy. Radiation safety protocols are in place to protect both the patient and visitors. However, the exact distance may vary based on the specific treatment and facility guidelines.
Choice C rationale:
Attaching a dosimeter to the client's gown is the correct action. A dosimeter measures the amount of radiation exposure received by the client. This information is crucial for healthcare providers to monitor the client's radiation dose, ensuring it stays within safe limits and effectively targets the cancer cells.
Choice D rationale:
Straining the client's urine is not directly related to brachytherapy with a low-dose radiation implant. This intervention is more relevant in situations where kidney stones or other urinary obstructions are suspected. It is not a standard practice for patients undergoing brachytherapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Documenting the client's vital signs obtained by an assistive personnel is correct. Documenting vital signs is fundamental and immediate requirement when admitting a client to ensure their current health status is accurately captured and can be monitored effectively.
Choice B rationale:
Charting a summary of the data at the change of the shift is incorrect. While it's essential to provide an update at shift change, this option suggests summarizing the data, which might not include all necessary details. Comprehensive documentation is crucial for continuity of care and accurate communication among healthcare providers. Documenting specific vital signs, assessments, interventions, and the client's response to those interventions is necessary for effective patient care.
Choice C rationale:
Noting whether the client has a living will is incorrect. While it's essential to be aware of a client's advanced directives, this information is typically gathered during the admission process or during routine assessments. It is not the immediate action to be taken upon admission. Vital signs and other immediate clinical data take precedence during the initial documentation process.
Choice D rationale:
Beginning charting with an evaluation of the data is incorrect. It is important to document objective data, such as vital signs, observations, and assessments, before making any evaluations or interpretations. Objective data provide the basis for clinical decisions and interventions. Starting with evaluations might lead to biased documentation, potentially overlooking important clinical findings.
Correct Answer is C
Explanation
- A. Contacting the facility chaplain to visit with the client may be helpful for some clients who have spiritual needs or concerns, but it does not address the client's expressed desire to go home. The nurse should respect the client's wishes and preferences and not impose their own beliefs or values on them.
- B. Explaining the process of leaving the facility against medical advice may discourage the client from pursuing their goal of going home and imply that they are making a wrong decision. The nurse should not judge or coerce the client, but rather provide them with information and support to make an informed choice.
- C. Making a referral for social services is the best action for the nurse to take, as it will help the client access resources and services that can facilitate their discharge planning and home care arrangements. The social worker can also assist with financial, legal, or emotional issues that may arise from the terminal diagnosis.
- D. Encouraging the client to continue with inpatient care may go against the client's wishes and values, and may cause them more distress and suffering. The nurse should respect the client's autonomy and dignity and support their quality of life goals.
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