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 A
Explanation
A. "Lifts head 45° when lying prone." By 2 months of age, infants begin lifting their heads about 45 degrees while on their stomachs, which is an early sign of developing neck and upper body strength.
B. "Rolls over from back to abdomen." Rolling from back to abdomen typically occurs around 6 months of age.
C. "No head lag when pulled into a sitting position." Head lag is still present at 2 months, but it gradually disappears by 4 months as neck muscles strengthen.
D. "Rolls over from abdomen to back." Rolling from abdomen to back typically occurs around 4 months of age, followed by rolling from back to abdomen at about 6 months.
Correct Answer is B
Explanation
A. Elevated temperature. An elevated temperature is a common symptom of infection, including bacterial pneumonia, but it is not a direct risk factor for aspiration. The concern for aspiration is more related to a child's ability to protect their airway.
B. Neurological deficit. A neurological deficit, such as a decreased level of consciousness or impaired swallowing reflexes, increases the risk of aspiration. A child with neurological impairment may have difficulty swallowing or protecting their airway, making them more prone to inhaling food, fluids, or other substances into the lungs, leading to aspiration pneumonia.
C. Inspiratory wheezing. Inspiratory wheezing is more likely to be associated with conditions like asthma or airway obstruction, not specifically with aspiration. It does not directly indicate a risk for aspiration.
D. Rapid respirations. Rapid respirations can be a sign of respiratory distress, common in pneumonia, but they do not directly indicate a risk for aspiration. The risk for aspiration is more closely linked to issues with swallowing and airway protection, not just the rate of respiration.
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