A nurse is caring for a client who is receiving radiation therapy through a sealed implant. Which of the following actions should the nurse take?

Instruct visitors to stand 0.6 m (2 feet) away from the client.

Wear a lead apron when providing care for the client.

Remove all bed linens from the client's room each day.

Place a dosimeter film badge at the client's bedside.

Answer and Explanation

The Correct Answer is B

A. Instruct visitors to stand 0.6 m (2 feet) away from the client: While maintaining distance can reduce radiation exposure, standard precautions for sealed implants typically require visitors to be limited in time and distance, but the priority for staff is proper protective equipment rather than only instructing visitors.

B. Wear a lead apron when providing care for the client: Wearing a lead apron is essential for staff safety when caring for a client with a sealed radiation implant. The apron shields the nurse from radiation exposure, which is the primary protective measure during direct care.

C. Remove all bed linens from the client's room each day: Frequent removal of linens is unnecessary for sealed radiation implants because the radiation source is contained. Standard precautions for linen handling are sufficient unless the linens are visibly contaminated with bodily fluids.

D. Place a dosimeter film badge at the client's bedside: Dosimeter badges are worn by staff to monitor personal radiation exposure, not placed at the client’s bedside. Proper usage involves staff wearing the badge on their body while providing care.

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

Explanation

Rationale for correct choices

• Shortness of breath: The client’s dyspnea indicates impaired oxygenation and potential progression of pneumonia or respiratory compromise. Rapid recognition is essential to prevent hypoxemia or respiratory failure. Persistent shortness of breath warrants immediate interventions such as supplemental oxygen, monitoring, and notifying the provider.

• Productive cough with yellow sputum: The sputum color and productivity suggest a bacterial respiratory infection, which is confirmed by the chest x-ray result (pneumonia) and elevated WBC count. This requires immediate treatment with antibiotics.

• Diminished lung sounds with crackles: Diminished breath sounds and crackles suggest alveolar consolidation or fluid accumulation in the lungs, consistent with pneumonia. These findings indicate impaired gas exchange and increased work of breathing. Prompt assessment ensures early intervention and prevents deterioration.

• Pleuritic chest pain rated 6/10: Moderate chest pain on inspiration can indicate inflammation of the pleura secondary to pneumonia or early complications such as empyema. Pain may limit deep breathing and coughing, increasing the risk of atelectasis and further respiratory compromise. Follow-up ensures pain management and effective pulmonary hygiene.

Rationale for Incorrect Findings

• Nausea without vomiting: While the client reports nausea, it is mild and not associated with dehydration or electrolyte disturbances at this time. It should be monitored but does not require immediate intervention.

• Able to move all extremities and oriented: Neurological status is intact, which is reassuring. No deficits are noted, and immediate follow-up is not required.

• Skin is moist, pedal pulses +2: Perfusion appears adequate. Vital signs and circulation findings do not indicate acute compromise needing urgent intervention.

• Bowel sounds normoactive, last bowel movement this morning, no difficulty urinating: Gastrointestinal and urinary functions are stable. These findings do not require immediate follow-up.

A. Administer an oral rehydration solution. B. Offer the child 1 cup of chicken broth. C. Encourage the child to eat gelatin D. Initiate a high-carbohydrate diet.

Correct Answer is A

Explanation

A. Administer an oral rehydration solution: Oral rehydration solutions (ORS) are specifically formulated to replace fluids and electrolytes lost during diarrhea. They are the first-line treatment for mild to moderate dehydration in children with gastroenteritis, helping prevent complications and restore hydration safely.

B. Offer the child 1 cup of chicken broth: While chicken broth provides some fluid, it is not balanced in electrolytes and sodium, and it may be too concentrated in sodium for a preschooler with diarrhea. ORS is more appropriate for correcting dehydration.

C. Encourage the child to eat gelatin: Gelatin is low in electrolytes and protein and does not adequately replace fluids lost from diarrhea. Relying on gelatin alone would not meet the child’s rehydration needs.

D. Initiate a high-carbohydrate diet: High-carbohydrate foods are not recommended during acute diarrhea because they can worsen osmotic diarrhea. Focus should be on fluid and electrolyte replacement rather than high-carbohydrate foods initially.

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A nurse is caring for a client who is receiving radiation therapy through a sealed implant. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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

Explanation

Exhibits A nurse is providing care for a preschooler who has acute gastroenteritis. Which of the following actions should the nurse take? (Click on the exhibit tabs for additional information about the client. There are three tabs that contain separate categories of data.)

Correct Answer is A

Explanation

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