A nurse on an oncology unit is caring for a client who is receiving internal radiation therapy. Which of the following actions should the nurse take?

Wear a lead apron when providing client care.

Allow visitors to hold the client's hand.

Leave the door to the client's room open.

Place the dosimeter him badge on the client's do

Answer and Explanation

The Correct Answer is A

Choice A Reason:

Wearing a lead apron when providing client care is appropriate. When caring for a client who is receiving internal radiation therapy, the nurse should take appropriate safety measures to minimize their exposure to radiation. Wearing a lead apron when providing care to the client helps shield the nurse's body from radiation exposure and reduces the risk of harm.

Choice B Reason:

Allowing visitors to hold the client's hand is inappropriate. Visitors should also be educated about radiation safety measures and should not be encouraged to have close contact with the client during internal radiation therapy.

Choice C Reason:

Leaving the door to the client's room open is inappropriate. Closing the door to the client's room can help contain radiation and limit its spread to other areas.

Choice D Reason:

Placing the dosimeter badge on the client's bed is inappropriate. The dosimeter badge should be worn by healthcare personnel to measure their radiation exposure. Placing it on the client's bed does not accurately measure the nurse's exposure and is not the correct use of the badge.

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Correct Answer is B

Explanation

Choice A reason:

Listening to the client's bowel sounds should not be implemented. While assessing bowel sounds is important, it is not the highest priority in this situation. The client's low serum potassium level indicates the potential for serious cardiac arrhythmias, so actions related to monitoring and addressing this electrolyte imbalance are more critical.

Choice B reason:

Initiate cardiac monitoring for the client is the correct answer. A serum potassium level of 2.8 mEq/L is significantly low and can lead to life-threatening cardiac arrhythmias. Initiating cardiac monitoring is crucial to assess the client's heart rhythm and ensure that any potential abnormalities are identified promptly.

Choice C reason:

Check the client's hand grasps should not be implemented. Assessing the client's hand grasps can provide information about muscle strength, but it is not the immediate priority when the client has a critically low potassium level.

Choice D reason:

Administer an IV potassium drip should not be implemented. Administering IV potassium is important for correcting the potassium imbalance, but the priority is to assess and monitor the client's cardiac status first. Rapid administration of potassium can lead to cardiac arrhythmias, so it's important to ensure the heart's stability through cardiac monitoring before administering potassium.

A. Administer the unit of packed RBCs over 1 hr. B. Initiate venous access with a 21-gauge needle. C. Use Y tubing with 0.9% sodium chloride when administering the transfusion D. client's first set of vital signs 1 hr. after initiating the transfusion

Correct Answer is C

Explanation

Choice A Reason:

Administering the unit of packed RBCs over 1 hour is not appropriate. Packed RBCs are usually administered over a longer period of time (typically 2 to 4 hours), as rapid infusion can lead to adverse reactions. The rate of administration should be based on institutional policy.

Choice B Reason:

Initiating venous access with a 21-gauge needle is not appropriate-. The needle size for venous access can vary based on the client's condition and the size of their veins. However, a larger gauge needle (e.g., 18-gauge or 20-gauge) is typically used for blood transfusions to ensure adequate flow.

Choice C Reason:

Blood products should be infused through administration sets designed specifcally for blood; use a Y-tubing or straight-tubing blood administration set that contains a filter designed to trap fibrin clots and other debris that accumulate during blood storage.

Choice D Reason:

The nurse should measure vital signs and assess lung sounds before the transfusion and again after the first 15 minutes and every 30 minutes to 1 hour (per agency policy) until 1 hour after the transfusion is completed.

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A nurse on an oncology unit is caring for a client who is receiving internal radiation therapy. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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