A nurse is caring for a pediatric client receiving radiation therapy to the abdominal area. Which of the following statements by the nurse promotes proper skin integrity for the client?
"Do not wash the area with strong soaps and do not rub the area dry, just pat it dry."
"Apply some triple antibiotic ointment to help the dryness and itching."
"You should get an abdominal binder and try to keep the area covered."
"You need to keep the area exposed to air and direct sunshine."
The Correct Answer is A
A. "Do not wash the area with strong soaps and do not rub the area dry, just pat it dry." Radiation therapy can cause skin irritation and dryness. Using mild soap, lukewarm water, and gently patting the area dry helps prevent further irritation and promotes skin integrity.
B. "Apply some triple antibiotic ointment to help the dryness and itching." Antibiotic ointments are not recommended unless there is an infection. Instead, radiation patients should use gentle, fragrance-free moisturizers as directed by their provider.
C. "You should get an abdominal binder and try to keep the area covered." Tight or restrictive clothing can further irritate the skin and increase the risk of breakdown in the radiation-exposed area.
D. "You need to keep the area exposed to air and direct sunshine." Direct sun exposure can worsen radiation burns and should be avoided. The skin in the treated area is more sensitive to UV rays and at a higher risk for damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Temperature 38.6° C (101.5° F)." A fever is not an indicator of improved hydration or effective fluid resuscitation. It may be related to an underlying infection, which could contribute to hypovolemia.
B. "Sunken anterior fontanel." A sunken fontanel is a sign of dehydration, indicating that the fluid replacement was not fully effective. If the treatment were successful, the fontanel should be normal (flat and soft).
C. "Tachycardia." Tachycardia is a sign of ongoing hypovolemia or distress. If fluid resuscitation was effective, the heart rate should return to normal for the infant's age.
D. "Capillary refill is 2 seconds." A capillary refill time of 2 seconds or less indicates adequate peripheral perfusion and improved circulation, showing that the fluid bolus was effective in restoring blood volume and perfusion.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}
Explanation
Temperature: The temperature decreased from 38.8° C (101.8° F) to 37.6° C (99.7° F), which indicates a potential improvement in the infection response as the body temperature is coming down.
WBC count: The WBC count increased slightly from 14,000/mm³ to 15,000/mm³, which is still elevated compared to the normal range (5,000 to 10,000/mm³). This suggests that the body is still responding to infection and could indicate a worsening condition if the trend continues or remains elevated.
Weight-bearing ability on the affected leg: The improvement in weight-bearing ability suggests that the condition of the leg is improving. This indicates that the condition is improving as the pain or swelling may have decreased.
Wound assessment: The wound culture is still pending, and although there is no specific description provided, a pending culture and the general condition of the wound (which can be assessed for redness, warmth, or exudate) might still indicate a worsening condition if there is continued inflammation or signs of spreading cellulitis.
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