A nurse is planning care for a client who is receiving internal brachytherapy. Which of the following interventions should the nurse include in the plan of care?

Place the client in a negative pressure room.

Dispose of the radioactive source in the client's trash can.

Limit each visitor to 1 hr per day.

Use long-handled forceps if the radioactive source is dislodged.

Answer and Explanation

The Correct Answer is D

A. Place the client in a negative pressure room: Negative pressure rooms are used for airborne precautions, such as tuberculosis, but are not required for internal brachytherapy. Clients receiving internal radiation require a private room with appropriate shielding to limit radiation exposure.

B. Dispose of the radioactive source in the client's trash can: Radioactive sources should never be discarded in regular trash. If dislodged, the source must be handled properly using protective equipment and disposed of in a designated lead container to prevent radiation exposure.

C. Limit each visitor to 1 hr per day: Visitors should be limited to 30 minutes per day and should maintain a distance of at least 6 feet from the client. This minimizes radiation exposure to family members and healthcare providers.

D. Use long-handled forceps if the radioactive source is dislodged: If the internal radiation source becomes dislodged, it should never be touched directly. Long-handled forceps should be used to carefully place the source in a lead-lined container to protect against radiation exposure.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

The first action the nurse should take is assess for dizziness when standing followed by increase dietary iron intake.

Rationale:

Assess for dizziness when standing: The client’s orthostatic hypotension (BP drops from 132/60 to 102/50 mmHg upon standing) and tachycardia (HR 108/min) suggest possible symptomatic anemia. Evaluating for dizziness ensures client safety and helps determine the severity of anemia-related hypoxia.

Increase dietary iron intake: The client has iron deficiency anemia (low hemoglobin, hematocrit, RBC count, and ferritin). Since they follow a vegan diet, increasing plant-based iron sources (e.g., leafy greens, legumes, fortified cereals) and vitamin C intake can improve iron absorption.

Incorrect:

Administer IV fluids: While anemia can cause orthostatic hypotension, fluid resuscitation is not the first-line intervention unless dehydration is present.

Check for signs of bleeding: The client reports no pain or discomfort, and there is no evidence of active bleeding. Anemia is more likely due to chronic dietary deficiency rather than acute blood loss.

Administer vitamin B12 supplements: The client’s vitamin B12 level is slightly low but not critically deficient. The primary issue is iron deficiency, not pernicious anemia.

A. Chest tube with a drainage system B. NG tube with suction apparatus C. Chest physiotherapy vest D. Peak flow meter

Correct Answer is C

Explanation

A. Chest tube with a drainage system: A chest tube is typically used for pneumothorax or pleural effusion, not as a routine treatment for cystic fibrosis. While some clients with severe lung disease may require one in emergencies, it is not standard home care equipment.

B. NG tube with suction apparatus: While some clients with cystic fibrosis may require enteral feeding for nutritional support, an NG tube with suction is not a standard home intervention. Suctioning is generally needed for acute gastrointestinal obstruction rather than routine CF management.

C. Chest physiotherapy vest: This device helps loosen and mobilize thick mucus from the airways, improving airway clearance and reducing the risk of infections. It is a critical component of daily CF management and is commonly used in home settings.

D. Peak flow meter: A peak flow meter is more commonly used in asthma to monitor airway obstruction. In CF, lung function is better assessed with spirometry rather than peak expiratory flow, making this device less useful for routine home monitoring.

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A nurse is planning care for a client who is receiving internal brachytherapy. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is caring for a client. Complete the following sentence by using the lists of options. The first action the nurse should take is ____ followed by _____ .

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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Correct Answer is C

Explanation

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