The client is hospitalized for insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial action by the nurse is to:

pick up the implant with gloved hands and place it in bedside container.

pick up the implant with long handled forceps and place it in a lead container.

call for the rapid response team.

call the radiation oncologist immediately.

Answer and Explanation

The Correct Answer is B

A. Picking up the implant with gloved hands does not ensure safety and proper handling of a radioactive material, as gloves do not provide adequate protection against radiation exposure.
B. Using long-handled forceps to pick up the implant and placing it in a lead container is the correct action, as it minimizes radiation exposure to the nurse and ensures the safe containment of the radioactive source.
C. Calling for the rapid response team is unnecessary in this scenario; the situation requires immediate containment of the radioactive material rather than emergency medical intervention.
D. Calling the radiation oncologist is not the first action; while it is important to inform the physician afterward, the priority is to secure the radioactive implant properly to prevent exposure.

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Correct Answer is B

Explanation

A. Measuring abdominal girth may be relevant for assessing potential complications like abdominal distention, but it is not the immediate priority in response to serosanguinous drainage from the nasogastric tube.
B. Continuing to monitor the drainage is appropriate, as serosanguinous fluid is common immediately after surgery and may gradually change as healing progresses. Monitoring allows for the identification of any changes that may require further intervention.
C. Notifying the physician may be necessary if the drainage increases or changes significantly, but immediate action is to observe and assess the drainage trend.
D. Irrigating the nasogastric tube is not warranted unless there is an obstruction or significant change in the drainage; it should only be done based on specific orders or protocols.

A. Bowel sounds, abdominal girth, and NG tube output B. Vital signs, cardiac rhythm, and peripheral pulses C. Blood Urea Nitrogen, Creatinine, and daily weight D. Respiratory rate, respiratory depth, and pulse oximetry

Correct Answer is B

Explanation

A. Bowel sounds, abdominal girth, and NG tube output provide important information about gastrointestinal function and the potential for complications like ileus or obstruction. However, they do not provide direct information regarding fluid volume status.
B. Vital signs (including blood pressure and heart rate), cardiac rhythm, and peripheral pulses are the first indicators to assess for decreased fluid volume. Hypovolemia often manifests as tachycardia, hypotension, and weak peripheral pulses, which are critical early signs of fluid depletion.
C. Blood Urea Nitrogen (BUN), creatinine, and daily weight are useful in assessing kidney function and long-term fluid status, but they may not be as immediate indicators of acute fluid volume changes in the immediate postoperative period.
D. Respiratory rate, depth, and pulse oximetry are important for assessing respiratory function and oxygenation. While fluid volume imbalances can impact respiratoryfunction, these parameters are not the most direct indicators of fluid volume status.

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The client is hospitalized for insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. The initial action by the nurse is to:

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Naxlex Comprehensive Predictor Exams

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