Page 1334 - Saunders Comprehensive Review For NCLEX-RN

Integrated Process: Nursing Process—Implementation
Content Area: Foundations of Care: Safety
Health Problem: N/A
Priority Concepts: Cellular Regulation; Safety
Reference: Ignatavicius, Workman, Rebar (2018), p. 389.

446. Answer: 4

Rationale: In the event that a radiation source becomes dislodged, the nurse
would first encourage the client to lie still until the radioactive source has been
placed in a safe, closed container. The nurse would use long-handled forceps to
place the source in the lead container that should be in the client’s room. The nurse
should then call the radiation oncologist and document the event and the actions
taken. It is not within the scope of nursing practice to insert a radiation implant.
Test-Taking Strategy: Note the strategic word, initial. The initial action would be
to prevent self-contamination from radiation exposure. This will direct you to the
correct option.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Implementation
Content Area: Foundations of Care: Safety
Health Problem: N/A
Priority Concepts: Cellular Regulation; Safety
Reference: Ignatavicius, Workman, Rebar (2018), p. 389.

447. Answer: 3

Rationale: In the neutropenic client, meticulous hand hygiene education is
implemented for the client, family, visitors, and staff. Not all visitors are restricted,
but the client is protected from persons with known infections. Fluids should be
encouraged. Invasive measures such as an indwelling urinary catheter should be
avoided to prevent infections.
Test-Taking Strategy: Eliminate option 1 because of the closed-ended wordall.
Next, eliminate option 2 because it is not reasonable to restrict fluids in a client
receiving chemotherapy who is at risk for fluid and electrolyte imbalances. Eliminate
option 4 because of the risk of infection that exists with this measure.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Nursing Process—Implementation
Content Area: Foundations of Care: Safety
Health Problem: N/A
Priority Concepts: Caregiving; Infection
Reference: Ignatavicius, Workman, Rebar (2018), p. 397.

448. Answer: 1

Rationale: The client’s self-report is a critical component of pain assessment. The

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