A nurse is caring for a client who is receiving a prescribed dose of internal radiation therapy. Which of the following actions should the nurse plan to perform?
Ensure the door to the client's room remains open.
Wear sterile gloves during patient care.
Wear a lead apron when providing client care.
Place a dosimeter on the client's gown.
The Correct Answer is C
A. Ensure the door to the client's room remains open: The door should be kept closed to minimize exposure to radiation. Keeping the door open increases the risk of radiation exposure to others in the area.
B. Wear sterile gloves during patient care: Sterile gloves are not required for care during internal radiation therapy unless there is direct contact with bodily fluids or radioactive materials. Standard precautions are sufficient.
C. Wear a lead apron when providing client care: A lead apron is recommended for healthcare workers to protect themselves from radiation exposure during internal radiation therapy. The lead apron absorbs radiation and helps reduce the risk of harmful exposure.
D. Place a dosimeter on the client's gown: The dosimeter is typically worn by healthcare workers to measure radiation exposure, not the client. The client would not wear a dosimeter in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Encourage frequent visits from friends: While social interaction can be beneficial, it’s important to consider the individual’s needs and preferences. Overstimulation from too many visitors can cause anxiety or confusion, which can worsen cognitive symptoms.
B. Keep the over-the-bed light on: This may be helpful in preventing falls or confusion at night. However, it’s essential to avoid excessive lighting as it can disrupt the circadian rhythm, potentially leading to sleep disturbances. A dim nightlight is more appropriate.
C. Apply restraints to the upper extremities: Restraints should not be used as a first-line approach. They can increase confusion, anxiety, and the risk of injury. Non-restrictive interventions, such as proper positioning and a calm environment, should be prioritized.
D. Play serene, soothing music: Soothing music can be a helpful intervention to reduce anxiety, agitation, and confusion in clients with dementia. Music has been shown to have a calming effect, which can help the client feel more relaxed and at ease.
Correct Answer is D
Explanation
A. Blood pressure 140/90 mm Hg: This blood pressure reading is elevated but does not specifically suggest a pulmonary embolism (PE). It could be due to other factors such as anxiety or pain, and it is not a primary indicator of PE.
B. Respiratory rate 12/min: A respiratory rate of 12/min is within the normal range (12-20 breaths per minute). A PE typically causes an increased respiratory rate as the body attempts to compensate for impaired oxygenation: normal respiratory rate does not suggest PE.
C. Temperature 40° C (104° F): A fever of 40° C (104° F) is significantly elevated and suggests an infection or inflammation. While a PE can cause mild fever, a temperature of 40° C is more commonly associated with infection rather than a pulmonary embolism.
D. Heart rate 120/min: A heart rate of 120/min is indicative of tachycardia, which is a common response to a pulmonary embolism. The body tries to compensate for reduced oxygenation by increasing heart rate. Tachycardia, along with other symptoms such as shortness of breath and chest pain, is a key indicator of PE.
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