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. Auscultating the abdomen for bowel sound activity is important, but the priority is addressing the dehisced and eviscerated wound.

B. Bringing additional sterile dressing supplies is a good idea, but the priority is addressing the dehisced and eviscerated wound.

C. Obtaining a sample of the drainage for laboratory analysis can wait until the client's immediate needs are addressed.

D. Preparing the client to return to the operating room is the priority to address the dehisced and eviscerated wound and prevent further complications.

A. Muscle atrophy. B. Low grade fever. C. Joint pain. D. Hematuria.

Correct Answer is D

Explanation

A. Muscle atrophy may indicate various underlying conditions but is not typically associated with an exacerbation of SLE. While it should be noted, it is not the most critical finding to report in this context.

B. Low-grade fever is a common symptom of SLE exacerbation and may not require immediate reporting unless accompanied by other concerning symptoms.

C. Joint pain is a hallmark symptom of SLE exacerbation but may not warrant immediate reporting unless it is severe or debilitating.

D. Hematuria can indicate lupus nephritis, a serious complication of SLE. Prompt reporting to the healthcare provider is crucial for appropriate management and prevention of further kidney damage.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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