The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require immediate intervention?

The UAP stands by the patient's bed for 60 minutes talking with the patient.

The UAP gives the patient a saline mouthwash to use for oral care.

The UAP places the patient's bedding in the laundry container inside the clients room.

The UAP flushes the toilet twice after emptying the patient's bedpan.

Answer and Explanation

The Correct Answer is A

A) The UAP stands by the patient's bed for 60 minutes talking with the patient:
This action requires immediate intervention because of the potential radiation exposure to the UAP. A temporary radioactive cervical implant involves placing a radioactive source in or near the patient's cervix. This implant emits radiation, and safety precautions are essential to limit exposure to others, including healthcare workers. Prolonged close contact, such as standing by the patient's bed for 60 minutes, increases the risk of radiation exposure to the UAP.

B) The UAP gives the patient a saline mouthwash to use for oral care:
There are no specific contraindications to using a saline mouthwash for oral care in patients with a radioactive implant. Saline mouthwash is commonly recommended for patients undergoing radiation therapy to soothe the mouth and prevent dryness or irritation. As long as the UAP is following standard infection control and safety precautions.

C) The UAP places the patient's bedding in the laundry container inside the client's room:
Bedding and linens from a patient with a radioactive implant can usually be handled and disposed of according to hospital guidelines for radioactive waste. Often, these linens are not considered to pose a significant radiation hazard after removal from the patient’s immediate area, especially if the patient is not emitting radiation outside the prescribed safety guidelines.

D) The UAP flushes the toilet twice after emptying the patient's bedpan:
After the patient has a radioactive implant, any bodily waste (urine, stool) can potentially contain small amounts of radiation. Flushing the toilet twice helps to ensure that any radioactive materials are effectively cleared. However, the UAP should be instructed to wear gloves and take other precautions to prevent contamination while handling the bedpan and ensuring proper disposal of waste.

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Correct Answer is D

Explanation

A. "Are you having any headaches?" : While headaches can be a side effect of medications, this question does not directly assess the effectiveness of baclofen. Baclofen is primarily used to reduce muscle spasms and improve muscle tone.

B. "How has your appetite been?": Changes in appetite can be related to many factors, including medication side effects, but this question does not address the primary purpose of baclofen, which is to manage muscle spasms.

C. "Does your urine look clear or cloudy?": The appearance of urine is not directly related to the effectiveness of baclofen. This question might be more relevant to assessing other conditions or medications that affect the urinary system.

D. "Are you having trouble with spasms?": Baclofen (Lioresal) is prescribed to manage and reduce muscle spasms in conditions like multiple sclerosis. Asking the client about their experience with muscle spasms directly assesses the effectiveness of the medication in managing their symptoms.

A. Limit fluid intake B. Utilize assistive devices as needed C. Schedule eye examinations every other year D. Double up on any missed scheduled medications

Correct Answer is B

Explanation

A) Limit fluid intake:
There is no evidence to suggest that limiting fluid intake is necessary or beneficial for clients with multiple sclerosis (MS). In fact, staying well-hydrated is often encouraged, especially for individuals with bladder dysfunction or those at risk for urinary retention or constipation, which are common symptoms of MS. Restricting fluid intake could exacerbate these issues and is not a priority in MS management.

B) Utilize assistive devices as needed:
The most important aspect of teaching for a client recently diagnosed with multiple sclerosis is to encourage the use of assistive devices as needed. MS often causes mobility issues, weakness, and coordination difficulties due to damage to the nervous system. Using devices like canes, walkers, or wheelchairs can significantly improve independence and safety, helping the client maintain mobility and prevent falls

C) Schedule eye examinations every other year:
Eye problems, such as optic neuritis or diplopia (double vision), are common in MS, but the frequency of eye exams depends on the individual’s symptoms. Regular eye exams are important, but every other year is generally not frequent enough. Most MS patients are advised to have annual eye exams or as recommended by their ophthalmologist, especially if they experience any changes in vision.

D) Double up on any missed scheduled medications:
Doubling up on missed medications is not recommended, as it can lead to overdose or increase the risk of side effects. It is important to follow the prescribed medication regimen and use strategies to help the client remember their medications, such as setting reminders or using a medication organizer.

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The nurse supervises the care of a patient with a temporary radioactive cervical implant. Which action by unlicensed assistive personnel (UAP), if observed by the nurse, would require immediate intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is making a home visit to a client with multiple sclerosis. The nurse reviews the home medications taken by the client. Which question should the nurse ask to determine the effectiveness of the client's medication, baclofen (Lioresal)?

Correct Answer is D

Explanation

The nurse is preparing discharge teaching for a client who is recently diagnosed with Multiple sclerosis. Which of the following is the most important to include in the patient teaching?

Correct Answer is B

Explanation

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