The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

Protect the skin of the radiation portal site from sunlight exposure.

Avoid washing the skin inside the radiation portal site.

Remove the ink marks of the portal after each radiation treatment.

Apply moisture lotions daily to the radiation portal site.

Answer and Explanation

The Correct Answer is A

A. Protecting the skin of the radiation portal site from sunlight exposure is crucial to prevent further damage to the irradiated area, as the skin becomes more sensitive during radiation therapy.

B. Washing the skin inside the radiation portal site should be done gently with mild soap and water, as directed by the healthcare provider, to maintain cleanliness and prevent infection. However, excessive rubbing or scrubbing should be avoided to minimize irritation.

C. The ink marks of the portal are used as reference points for accurate delivery of radiation and should not be removed until instructed by the healthcare provider or radiation therapist.

D. Moisturizing the radiation portal site can help alleviate dryness and discomfort associated with radiation therapy, but it should be done sparingly and with products recommended by the healthcare provider to avoid potential interactions or interference with the treatment.

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Correct Answer is D

Explanation

A. Hemoglobin levels primarily indicate the oxygen-carrying capacity of the blood and are not typically affected in conditions associated with petechiae and ecchymosis.

B. White blood cell count may be elevated in response to infection but is not directly related to the presence of petechiae and ecchymosis.

C. Red blood cell count primarily reflects the oxygen-carrying capacity of the blood and is not typically affected in conditions associated with petechiae and ecchymosis.

D. Platelet count is crucial in assessing for thrombocytopenia, a condition characterized by low platelet levels, which can lead to increased bleeding and bruising, including petechiae and ecchymosis.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

The rationale for selecting impaired gas exchange is based on the clinical manifestations presented by the client. The client's difficulty in breathing, the need to pause to catch breath, the ineffectiveness of the rescue inhaler, and the expressed feeling of nervousness during episodes are indicative of a compromised gas exchange. This is further supported by the objective data: an oxygen saturation of 88% on room air is below normal levels, suggesting that the client is not receiving adequate oxygen. Expiratory wheezes indicate an obstruction of airflow, commonly seen in asthma attacks, which can impair gas exchange. Therefore, the nurse's assessment and the client's symptoms align with the diagnosis of impaired gas exchange, necessitating immediate intervention to improve the client's respiratory function.

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The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

Correct Answer is D

Explanation

Patient Data. Exhibits Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize dropdown as the priority problem for this client, as evidenced by the client's statement, dropdown.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

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