A 45-year-old woman has just undergone a radical hysterectomy for invasive cervical cancer. Prior to the surgery, the healthcare provider explained to the client that after the surgery an internal source of radiation would be placed near the tumor site to aid in reducing recurrence. Based on this information, the nurse knows to educate the client on which safety precaution?

The client should avoid crowded places.

The client should avoid eating fresh fruits and vegetables.

The client should maintain at least 6 feet from any visitors.

The client should avoid washing off the radiation tattoo markings.

Answer and Explanation

The Correct Answer is C

A. Avoiding crowded places is a precaution related to general health and infection control but is not specifically linked to internal radiation therapy.
B. Avoiding fresh fruits and vegetables is not required for internal radiation therapy. Dietary restrictions are not typically necessary unless specified by the healthcare provider.
C. For internal radiation therapy, maintaining distance from others, typically around 6 feet, is important to minimize radiation exposure to others. This safety measure helps reduce the risk of radiation exposure to family members and visitors.
D. Radiation tattoo markings are used to ensure proper placement of the radiation source and should not be washed off. However, this precaution does not directly relate to safety around radiation exposure.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Using a portable electronic thermometer is incorrect as the device must be dedicated to the client to avoid cross-contamination.
B. Wiping the stethoscope with alcohol after use is insufficient because alcohol-based sanitizers are ineffective against C. difficile spores. The stethoscope should be cleaned with bleach-based disinfectant.
C. Removing the protective gown before leaving the client's room is correct as it prevents the spread of C. difficile spores outside the isolation area.
D. Removing the protective gown before removing gloves is incorrect. Gloves should be removed first to prevent contamination when removing the gown.

A. A change in the Glasgow Coma Scale score from 13 to 10 B. Diplopia C. Ataxia D. A drop in heart rate from 76 to 70/min

Correct Answer is A

Explanation

A. A decrease in the Glasgow Coma Scale score from 13 to 10 indicates a significant change in consciousness and may suggest worsening of the brain injury. This is a critical sign that requires immediate reporting and evaluation.
B. Diplopia (double vision) can be a concerning symptom, but it is not as immediately critical as a significant change in the Glasgow Coma Scale score. It still warrants attention but may not be the highest priority.
C. Ataxia (lack of voluntary coordination of muscle movements) is a serious symptom that could indicate worsening of the brain injury but is not as immediately critical as a significant change in the Glasgow Coma Scale score.
D. A drop in heart rate from 76 to 70/min is generally not significant in the context of mild TBI. Changes in heart rate are less critical compared to changes in the level of consciousness.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new diagnosis of Clostridium difficile and is placed on contact precautions. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations is the priority for the nurse to report to the healthcare provider?

Correct Answer is A

Explanation

A nurse is caring for a client who has been diagnosed with leukemia. The nurse's most recent assessment reveals the presence of ecchymoses on the client's sacral area and petechiae on the forearms. Based on the most recent assessment findings, the nurse should perform which action?

An adult client in the intensive care unit (ICU) with a central venous catheter has developed signs and symptoms that are suggestive of a central line-associated bloodstream infection (CLABSI). What is most likely the cause of the infection?

A nurse is caring for a client who has hemophilia A and hemarthrosis of the left knee. Which of the following actions should the nurse take?

The nurse is assessing a client with a new diagnosis of multiple sclerosis. Which manifestations would the nurse expect to see that are common early signs of multiple sclerosis?

A nurse is caring for a client who has an infection. The nurse should use which of the following strategies to prevent the transmission of the client's infection?

A nurse at an ophthalmology clinic is providing teaching to a client who has open-angle glaucoma and a new treatment regimen of timolol and pilocarpine eye drops. Which of the following instructions should the nurse provide?

A client survived a workplace accident that claimed the lives of many of the client's colleagues several months ago. The client has recently sought care for the treatment of depression. How should the nurse best understand the client's current mental health problem?