A client presents to the emergency department seeking treatment for radiation burns. The nurse should develop the client's plan of care based on which of the following?

The duration of contact with the agent.

The type, dose, and length of exposure.

The pathway of flow through the body.

The temperature to which the skin is heated.

Answer and Explanation

The Correct Answer is B

A. The duration of contact with the agent: While duration is important, it alone does not provide a comprehensive understanding of radiation burns, which require considering the type and dose of radiation as well.

B. The type, dose, and length of exposure: These factors are crucial in assessing the severity and necessary treatment for radiation burns. The type of radiation (e.g., alpha, beta, gamma), the dose

received, and the length of exposure all determine the extent of tissue damage and appropriate interventions.

C. The pathway of flow through the body: This is more relevant to internal contamination with radioactive substances rather than external radiation burns.

D. The temperature to which the skin is heated: Temperature is a factor in thermal burns, not radiation burns. Radiation burns result from energy transfer, not heat.

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Correct Answer is B

Explanation

A. Obtain pulse oximetry every two hours: While monitoring oxygen saturation is important in assessing respiratory status, it is not a direct intervention for preventing atelectasis. It is more of an assessment tool to evaluate the effectiveness of interventions aimed at preventing atelectasis.

B. Teach the client how to use the incentive spirometer: Incentive spirometry is a valuable tool for preventing atelectasis postoperatively by promoting deep breathing and lung expansion. Teaching the client how to use the incentive spirometer and encouraging its frequent use can help maintain lung volume and prevent collapse of alveoli.

C. Instruct the client to practice abdominal breathing: While abdominal breathing can be beneficial for promoting relaxation and reducing anxiety, it is not as effective as incentive spirometry in preventing atelectasis postoperatively.

D. Encourage oral fluid intake of 2000 mL/24 hours: Adequate hydration is important for overall health and respiratory function, but it is not specifically targeted at preventing atelectasis. While hydration can help maintain airway secretions thin, it is not the primary intervention for preventing atelectasis after a lobectomy.

A. Client develops petechiae on the arms, legs, and abdomen. B. Health care provider orders Coumadin 2.5 mg P.O. to begin today. C. Client develops slight ecchymosis at the venipuncture site. D. Client's partial thromboplastin time (PTT) is 70 seconds and the control is 25-40 seconds.

Correct Answer is D

Explanation

A. Client develops petechiae on the arms, legs, and abdomen: Petechiae can indicate thrombocytopenia, which may be a complication of heparin therapy but is not an urgent concern unless severe or associated with bleeding.

B. Health care provider orders Coumadin 2.5 mg P.O. to begin today: Coumadin (warfarin) is often initiated as a bridge therapy or overlap with heparin therapy in pulmonary embolism management. This order is not necessarily inappropriate and may be part of the treatment plan.

C. Client develops slight ecchymosis at the venipuncture site: Ecchymosis at the venipuncture site can occur due to minor trauma during the insertion of IV lines or blood draws and is not necessarily indicative of a complication requiring immediate notification of the healthcare provider.

D. Client's partial thromboplastin time (PTT) is 70 seconds and the control is 25-40 seconds: A significantly elevated PTT indicates a potential overdose of heparin, putting the client at risk of bleeding complications. This finding warrants immediate notification of the healthcare provider for further evaluation and possible adjustment of heparin therapy.

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A client presents to the emergency department seeking treatment for radiation burns. The nurse should develop the client's plan of care based on which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following a left lobectomy for lung cancer. The nurse should prioritize which of the following interventions to prevent atelectasis?

Correct Answer is B

Explanation

A nurse is caring for a client diagnosed with a pulmonary embolism that is placed on a continuous heparin infusion. The nurse should notify the health care provider for which of the following findings?

Correct Answer is D

Explanation

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