A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following actions should the nurse take? (Select all that apply.)

Limit visitors to 30 min per day.

Instruct visitors who are pregnant to remain 3 feet from the client.

Wear a lead apron when providing care.

Place the client in a semi-private room.

Close the door to the client's room.

Answer and Explanation

Correct Answer : A,C,E

Rationale:

A. Limit visitors to 30 min per day: Time restrictions help minimize radiation exposure to visitors. Short visits reduce the cumulative dose received, which is especially important for non-staff individuals who are not regularly monitored for radiation exposure.

B. Instruct visitors who are pregnant to remain 3 feet from the client: Pregnant individuals should avoid close contact with radiation sources due to fetal sensitivity. Maintaining a 3-foot distance helps reduce exposure to scattered radiation from the sealed implant.

C. Wear a lead apron when providing care: A lead apron provides protection against scatter radiation, particularly during direct, prolonged care. Nurses should also stand as far away from the source as possible and work efficiently to limit time near the implant.

D. Place the client in a semi-private room: Clients with sealed radiation implants require a private room to protect others from radiation exposure. A semi-private room would place another patient at unnecessary risk and violates radiation safety protocols.

E. Close the door to the client's room: Keeping the door closed helps contain radiation within the room, thereby protecting other individuals in the surrounding area. It is a standard precaution for clients receiving internal radiation therapy.

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Correct Answer is ["A","D","E"]

Explanation

Rationale:

A. Provide a quiet environment for the client: Minimizing noise and stimulation helps reduce stress and prevents spikes in intracranial pressure (ICP). A calm environment is essential for neurologically compromised clients.

B. Encourage the client to cough and deep breathe: Coughing can increase thoracic pressure and, consequently, ICP. In clients with elevated ICP, activities that increase intrathoracic or intra-abdominal pressure should be avoided to prevent worsening brain injury.

C. Obtain client vital signs every 8 hr: Clients with increased ICP require frequent monitoring, often hourly or every 2–4 hours, to detect changes in neurologic status or signs of Cushing's triad. Every 8 hours is insufficient for early intervention.

D. Maintain the head of the bed at a 30 degree angle: Elevating the head promotes venous outflow from the brain without compromising perfusion. A 30-degree elevation is a commonly recommended position to help control ICP levels.

E. Administer stool softeners to the client: Straining during bowel movements increases intra-abdominal pressure and can elevate ICP. Stool softeners reduce this risk and are a supportive intervention in the management of increased ICP.

A. Pain level of 1 on a scale of 0 to 10 B. Capillary refill time 1 second C. BMI 35 D. Oxygen saturation 97% on room air

Correct Answer is C

Explanation

Rationale:

A. Pain level of 1 on a scale of 0 to 10: A low pain score suggests effective pain management and is not associated with poor wound healing. In fact, well-controlled pain can facilitate mobility and participation in recovery activities, both of which support healing.

B. Capillary refill time 1 second: This finding reflects good peripheral perfusion, indicating adequate circulation and oxygen delivery to tissues, which are essential for optimal wound healing.

C. BMI 35: A BMI of 35 indicates obesity, which is a known risk factor for delayed wound healing. Excess adipose tissue reduces vascularity, increases tension on wound edges, and raises the risk of infection and dehiscence.

D. Oxygen saturation 97% on room air: Normal oxygen saturation ensures tissues are receiving sufficient oxygen to support cellular repair and regeneration. This value supports wound healing rather than delaying it.

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A nurse is caring for a client who has lung cancer and has a sealed radiation implant. Which of the following actions should the nurse take? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure following a traumatic brain injury. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

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Correct Answer is C

Explanation

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