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 B
A. "Limit each of the client's visitors to 2 hr per day."
This is incorrect. While visitors should have their exposure limited, the recommended duration is typically much shorter (around 30 minutes to 1 hour), not 2 hours. This is to reduce radiation exposure.
B. "Instruct visitors to stay 1 m (3.3 feet) away from the client."
This is correct. For clients undergoing brachytherapy with a low-dose radiation implant, visitors should maintain a safe distance, usually at least 6 feet (1.8 meters), but some guidelines may state a minimum of 3.3 feet (1 meter) for safety, depending on the specific radiation dose and facility protocols.
C. "Attach a dosimeter to the client's gown."
This is incorrect. Dosimeters are generally worn by healthcare providers, not the patient. The primary purpose is to measure the radiation exposure of healthcare workers, not the patient.
D. "Strain the client's urine."
This is incorrect. Straining urine is not necessary for a patient undergoing brachytherapy. However, it may be important to monitor the urine for signs of radiation leakage, but straining is not a routine part of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
- A: Correct. Broccoli is a vegetable that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
- B: Correct. Yogurt is a dairy product that does not contain tyramine, which can interact with phenelzine and cause a hypertensive crisis.
- C: Incorrect. Pepperoni pizza contains pepperoni, cheese, and tomato sauce, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
- D: Cream cheese is a dairy product that contains little or no tyramine and is therefore, safe in a client taking phenelzine.
- E: Incorrect. Bologna sandwich contains bologna, bread, and mayonnaise, which are all sources of tyramine, which can interact with phenelzine and cause a hypertensive crisis.
Correct Answer is B
Explanation
Choice A rationale:
Uterine rupture typically presents with intense, constant abdominal pain and signs of shock. However, the absence of visible bleeding in the abdominal cavity makes this choice less likely in this case.
Choice B rationale:
Placental abruption involves the premature separation of the placenta from the uterine wall before delivery. The sudden, severe abdominal pain, moderate vaginal bleeding, persistent uterine contractions, and signs of hypovolemic shock (low blood pressure, rigid abdomen) are indicative of placental abruption. This condition requires immediate medical intervention due to the risk of fetal and maternal compromise.
Choice C rationale:
Placenta previa occurs when the placenta partially or completely covers the cervical opening. It typically presents with painless, bright red vaginal bleeding. The severe abdominal pain described in the scenario is inconsistent with placenta previa.
Choice D rationale:
Amniotic fluid embolus is a rare and life-threatening condition in which amniotic fluid enters the maternal bloodstream, causing an allergic reaction. It can lead to sudden cardiovascular collapse. Although it can cause respiratory distress and hypotension, it does not usually present with severe abdominal pain or uterine contractions.
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