A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care?

Limit each of the client's visitors to 1hr per day

Remove dirty linens from the room after double bagging

Wear a dosimeter film badge while in the client's room

Ensure family members remain at least 1m (3.2 feet) from the client

Answer and Explanation

The Correct Answer is C

A. Limit each of the client's visitors to 1 hr per day: Visitor restrictions for clients with sealed radiation implants typically focus on limiting cumulative exposure to radiation rather than a strict daily time limit. The exact duration may vary, but monitoring personal exposure is more critical for staff safety.

B. Remove dirty linens from the room after double bagging: For sealed radiation implants, the radioactive source remains contained, and linens are not highly radioactive. Standard precautions are sufficient, so special double-bagging is not required unless the linens are contaminated with bodily fluids.

C. Wear a dosimeter film badge while in the client's room: Staff who care for clients with sealed radiation implants must wear a dosimeter to monitor cumulative radiation exposure. This ensures that occupational safety limits are not exceeded and provides documentation of exposure levels, which is a key safety measure in the plan of care.

D. Ensure family members remain at least 1 m (3.2 feet) from the client: Family members may need limited exposure, but strict distance alone is not sufficient for safety or required for all types of sealed implants. Staff exposure monitoring via dosimeter is more critical, as they spend more time in the room and are at greater risk for cumulative exposure.

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Correct Answer is C

Explanation

A. Type 1 diabetes mellitus: Type 1 diabetes is not directly linked to an increased risk of cervical cancer. While chronic illnesses can affect overall health, they are not specific risk factors for cervical neoplasia.

B. Hypertension: Hypertension is a cardiovascular condition and does not contribute to the development of cervical cancer. It is not considered a risk factor in gynecologic oncology.

C. History of STIs: A history of sexually transmitted infections, particularly human papillomavirus (HPV), is a major risk factor for cervical cancer. HPV infection can cause cellular changes in the cervix that may progress to malignancy if not detected and managed early.

D. Nulliparity: While nulliparity has been associated with a slightly increased risk in some cancers, it is not as significant a risk factor for cervical cancer as HPV or other STIs. The primary focus in cervical cancer risk assessment is exposure to HPV.

A. Test the glucose level of the client's pulmonary secretions. B. Ask the client to speak after air instillation. C. Auscultate the client's stomach during air instillation. D. Test the pH level of the client's gastric aspirate

Correct Answer is D

Explanation

A. Test the glucose level of the client's pulmonary secretions: Testing glucose in pulmonary secretions is not a reliable method for verifying NG tube placement. Pulmonary secretions may have variable glucose levels and cannot confirm gastric placement, making this method unsafe for ensuring the tube is correctly positioned.

B. Ask the client to speak after air instillation: Having the client speak after air instillation is not a valid or safe method to confirm NG tube placement. Speaking does not provide any reliable indication of whether the tube is in the stomach or lungs and could lead to a false sense of security.

C. Auscultate the client's stomach during air instillation: Listening for a “whoosh” of air over the stomach has been a traditional practice but is unreliable and not recommended as the sole method. Air may also enter the lungs, producing a similar sound and potentially causing harm if feeding is initiated in a malpositioned tube.

D. Test the pH level of the client's gastric aspirate: Measuring the pH of aspirated gastric contents is a safe and effective method to confirm NG tube placement. Gastric fluid typically has a pH of 1–5, whereas respiratory secretions are more alkaline. This provides reliable verification before initiating enteral feeding.

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A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for 1 week. Which of the following should the nurse include in the plan of care?

Nursing Test Bank

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