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 1 hr 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 1 m (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. - This is not necessary specifically due to the presence of the radiation implant. Visitation restrictions should be based on hospital policy and

the client's condition, not solely on the presence of a radiation implant.

B. Remove dirty linens from the room after double bagging. - This is a standard infection control measure and is not specific to caring for a client with a radiation implant.

C. Wear a dosimeter film badge while in the client's room. - Healthcare workers who care for clients with sealed radiation implants should wear dosimeter film badges to monitor their radiation exposure levels.

D. Ensure family members remain at least 1 m (3.2 feet) from the client. - While limiting exposure to radiation is important, maintaining distance alone may not provide adequate

protection. Healthcare workers should follow appropriate safety precautions and use shielding as necessary when caring for clients with radiation implants.

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Correct Answer is B

Explanation

A. While it's important for the client to empty their bladder before surgery to reduce the risk of complications, administering a preoperative injection typically requires monitoring the client closely for any adverse reactions rather than immediately taking them to the bathroom.

B. Asking the client to verify the surgical site helps prevent wrong-site surgery and ensures proper patient safety protocols are followed.

C. Reviewing deep breathing and coughing exercises is an important preoperative teaching, but it's not typically done immediately after administering a preoperative injection.

D. Raising the side rails on the bed is a safety measure to prevent falls, but it's not directly related to administering a preoperative injection.

A. Adjust the straps on the harness once per week. B. Use only ultra-thin diapers applied over the straps. C. Maintain the child in a prone position while the harness is in place. D. Gently massage the skin under the straps once per day.

Correct Answer is D

Explanation

A. Adjusting the straps on the harness once per week is not recommended. The straps should only be adjusted by a healthcare provider to ensure proper fit and alignment, as incorrect adjustments can compromise the effectiveness of the treatment.

B. Using ultra-thin diapers applied over the straps is incorrect. Diapers should be placed under the harness to prevent soiling and maintain the harness's effectiveness. Placing diapers over the straps can interfere with proper positioning.

C. Maintaining the child in a prone position while the harness is in place is not necessary. The Pavlik harness is designed to keep the hips in a flexed and abducted position, and the infant can remain in various positions that are comfortable and safe.

D. Gently massaging the skin under the straps once per day is correct. This helps prevent skin irritation and promotes circulation. Guardians should also check for redness or irritation and ensure the harness fits properly to avoid pressure injuries.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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