A nurse is teaching a client who is receiving radiation therapy about skin protection. Which of the following client statements indicates an understanding of the teaching?
"I will expose the irradiated area of skin to the sun for no more than 30 minutes per day."
"I will apply my favorite unscented lotion to the irradiated area of skin twice each day."
"I will use my hand instead of a washcloth to wash the irradiated area of skin."
"I will make sure I have sterile water to wash the irradiated area of skin.”
The Correct Answer is C
Rationale:
A. "I will expose the irradiated area of skin to the sun for no more than 30 minutes per day.": Skin that has been irradiated is highly sensitive to sunlight, and any direct exposure can increase the risk of burns and further damage. Clients should avoid sun exposure entirely on affected areas.
B. "I will apply my favorite unscented lotion to the irradiated area of skin twice each day.": Applying lotion may be appropriate if recommended by the radiation oncology team, but the client should avoid using any lotion, cream, or ointment not approved for use on irradiated skin, as some products can irritate the area.
C. "I will use my hand instead of a washcloth to wash the irradiated area of skin.": Using the hand is the safest method for cleansing irradiated skin, as washcloths can cause friction, irritation, or breakdown. Gentle washing helps protect fragile skin and prevent injury during radiation therapy.
D. "I will make sure I have sterile water to wash the irradiated area of skin.": Sterile water is not required for routine skin care of irradiated areas. Mild soap and lukewarm tap water are typically sufficient unless the provider specifies otherwise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "Your provider understands your illness and is acting according to your best interests.": This statement does not address the client’s concerns and may minimize their feelings. It shifts focus away from the client’s perspective rather than supporting their right to express concerns about discharge timing.
B. "I know you will be able to recover faster at home.": This statement assumes the provider’s decision is correct and discourages the client from expressing concerns. It does not advocate for the client or ensure their voice is heard in care planning.
C. "I will tell the provider about your concerns.": Communicating the client’s concerns to the provider demonstrates client advocacy. The nurse acts on behalf of the client to ensure their preferences, questions, and safety needs are considered in the discharge decision.
D. "I will contact your insurance company to see if they will pay for you to be here longer.": While insurance involvement may be relevant, the primary role of the nurse as an advocate is to convey the client’s concerns to the healthcare team rather than directly managing insurance coverage issues.
Correct Answer is C
Explanation
Rationale:
A. A client who has dementia: Dementia affects cognitive function but does not inherently increase susceptibility to respiratory complications from mold exposure. While general health monitoring is important, this client is not at high risk for mold-related adverse effects.
B. A client who has osteoarthritis: Osteoarthritis primarily affects joints and mobility. It does not compromise the respiratory system or immune response in a way that would increase vulnerability to mold exposure.
C. A client who has cystic fibrosis: Clients with cystic fibrosis have impaired mucociliary clearance and chronic respiratory vulnerability, making them more susceptible to respiratory infections and complications from environmental mold exposure. Mold inhalation can exacerbate pulmonary symptoms and lead to significant health risks.
D. A client who has chronic hypertension: Hypertension affects the cardiovascular system but does not directly increase susceptibility to respiratory complications from mold. This client is not considered high risk for adverse effects from mold exposure.
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