A home health nurse is caring for a client who has terminal cancer. The client tells the nurse they wish to stop their chemotherapy treatments. Which of the following statements should the nurse make?

Rationale:
A. Assess pressure points every 24 hr: Skin assessment should be performed at least every shift or more frequently in high-risk clients. Waiting 24 hours between assessments increases the risk of progression from erythema to ulceration due to unrelieved pressure.

B. Turn and reposition the client every 3 hr while in bed: Clients at risk for pressure injuries should be repositioned at least every 2 hours in bed to promote circulation and reduce tissue ischemia. Extending this interval to 3 hours is inadequate for prevention or healing.

C. Teach the client to shift his weight every 15 min while sitting: Teaching the client to perform weight shifts every 15 minutes reduces pressure on the ischial areas, promoting blood flow and preventing further skin breakdown. This intervention empowers self-care and is a key preventive strategy for wheelchair-bound clients.

D. Place the client upright on a donut-shaped cushion: Donut cushions can impair circulation around the pressure site by concentrating pressure on surrounding tissue, worsening ischemia and tissue damage. Pressure-redistribution cushions or gel pads are safer alternatives.

Rationale:
A. Limit visitors to 30 min per day: Limiting the duration of visitors helps minimize radiation exposure to others. Only short, necessary visits are allowed, and visitors are advised to maintain a safe distance to reduce the cumulative radiation dose received during contact with the client.

B. Place the client in a semi-private room: Clients with sealed internal radiation implants should always be placed in a private room to protect others from unnecessary radiation exposure. A semi-private room would increase the risk of exposing other patients to radiation.

C. Instruct visitors who are pregnant to remain 3 feet from the client: Pregnant visitors should be instructed not to enter the client’s room at all because of the high sensitivity of the fetus to radiation exposure.

D. Wear a lead apron when providing care: The nurse must wear a lead apron while providing direct care to shield against radiation exposure. The nurse should also stand at the client’s side rather than directly in front of or behind the radiation source to minimize exposure intensity.

E. Close the door to the client’s room: Keeping the client’s door closed helps contain the radiation within the room, preventing unnecessary exposure to staff and other clients in nearby areas. It is part of the standard protective measures for clients undergoing internal radiation therapy.