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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Cleansing the insertion site daily: Frequent cleansing of an epidural insertion site is not recommended because excessive manipulation increases the risk of infection. Standard practice is to keep the site clean and dry, assessing it regularly without daily cleaning unless contamination occurs.
B. Covering the insertion site with a transparent dressing: Using a sterile, transparent dressing allows continuous visualization of the insertion site for early signs of infection, leakage, or inflammation. It protects the site while permitting ongoing assessment, which is essential for clients receiving epidural analgesia.
C. Administering supplemental opioids as needed: Supplemental opioids should be used cautiously in clients with epidural analgesia because they can increase the risk of respiratory depression and sedation. Pain management should primarily rely on the epidural infusion and follow prescribed protocols rather than routine PRN systemic opioids.
D. Replacing the infusion tubing every 72 hr: Epidural infusion tubing typically should be replaced according to institutional protocol, often every 24 hours, not 72 hours, to reduce the risk of infection. Extending tubing changes beyond recommended intervals increases the likelihood of contamination and catheter-related complications.
Correct Answer is D
Explanation
A. Wear an N95 respirator: An N95 respirator is required for airborne precautions, such as with tuberculosis. Neutropenic clients are not at risk for transmitting infections but are highly susceptible to acquiring them, so an N95 is not necessary.
B. Insert an indwelling urinary catheter to monitor urinary output: Invasive devices increase the risk of infection in neutropenic clients. Catheterization should be avoided unless absolutely necessary, as it can introduce pathogens.
C. Monitor the client's vital signs every 8 hr: Neutropenic clients require more frequent monitoring to detect early signs of infection. Waiting 8 hours between assessments may delay recognition of sepsis or other complications.
D. Use a dedicated stethoscope: Using a dedicated stethoscope and other equipment for the neutropenic client helps prevent the transmission of pathogens from other patients. This is a key component of neutropenic (protective) precautions to reduce infection risk.
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