A nurse is reinforcing teaching with a client who has cancer and is undergoing external radiation therapy. Which of the following instructions should the nurse include in the teaching?
"Wash the site daily with warm water
"Wash skin markings off after each treatment.
"Apply lotion to the site after treatment."
"Cover the site with a transparent dressing
The Correct Answer is A
A) "Wash the site daily with warm water": The nurse should instruct the client to wash the radiation treatment site gently with warm water and mild soap (without scrubbing or using harsh soaps). This helps to cleanse the skin without irritating it. Keeping the skin clean can help prevent infection and minimize irritation during the course of radiation therapy. It's important not to use hot water or harsh chemicals, as the skin in the treated area can be sensitive.
B) "Wash skin markings off after each treatment": Skin markings are placed on the client's skin by the radiation oncologist to ensure the radiation is targeted precisely. These marks should not be washed off, as they are necessary for the planning and delivery of radiation. Washing off the marks could affect the accuracy of the treatment.
C) "Apply lotion to the site after treatment": While it may seem like a good idea to apply lotion to moisturize the skin, clients undergoing radiation therapy should avoid applying any lotions, creams, or ointments to the radiation site unless specifically prescribed by their healthcare provider. Some lotions or creams may contain chemicals that could irritate the skin further or interfere with the radiation treatment. Only approved products should be used.
D) "Cover the site with a transparent dressing": Covering the radiation treatment site with a transparent dressing is typically not recommended unless the client has an open wound or is instructed to do so by the healthcare provider. The treated skin should be left exposed to air to promote healing unless advised otherwise. Covering the site could trap moisture, leading to skin irritation or infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Hot cocoa: Hot cocoa contains the least amount of caffeine compared to the other beverages listed. While it does contain some caffeine, it is significantly lower than coffee, tea, or cola. A typical 8 oz serving of hot cocoa contains approximately 3-10 mg of caffeine, making it the best option for a client looking to reduce caffeine intake.
B) Brewed green tea: Brewed green tea contains more caffeine than hot cocoa. On average, an 8 oz cup of brewed green tea contains about 25-30 mg of caffeine, which is more than cocoa but less than coffee or cola. Although green tea has health benefits, it may not be the best option for those trying to limit caffeine intake.
C) Instant coffee: Instant coffee typically contains more caffeine than brewed green tea or hot cocoa. An 8 oz serving of instant coffee can contain around 30-90 mg of caffeine, depending on the brand and how it is prepared. While it provides a caffeine boost, it is not a good choice for someone seeking to reduce caffeine consumption.
D) Cola soft drink: Cola soft drinks contain a moderate amount of caffeine, usually about 30 mg per 8 oz serving. While this is less than coffee or tea, it still contains more caffeine than hot cocoa and could be a concern for someone trying to cut back on caffeine.
Correct Answer is ["A","B","E","F"]
Explanation
A. Maintain a safe and private environment for the client – Anticipated. Providing a secure and private setting helps support the client emotionally and ensures confidentiality during a sensitive situation.
B. Request a consult for case management – Anticipated. Case management can coordinate follow-up care, legal support, counseling, and additional resources for the client.
C. Provide resources to the client for the local Alcoholics Anonymous chapter – Contraindicated. There is no indication that the client has an alcohol use disorder. The focus should remain on addressing the sexual assault.
D. Contact children and youth services – Contraindicated. The client is a college student and an adult. There is no mention of minors being involved, so reporting to child protective services is unnecessary.
E. Provide resources for local support services – Anticipated. Connecting the client with crisis centers, advocacy groups, and counseling services is essential for emotional and psychological support.
F. Administer sexually transmitted infection prophylaxis – Anticipated. Post-exposure prophylaxis (PEP) for sexually transmitted infections (STIs), including gonorrhea, chlamydia, and HIV, should be administered to prevent potential infection.
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