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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Using a large gauge IV catheter can increase the risk of bleeding in a thrombocytopenic patient.
B. Wrapping bruised areas with elastic bandage dressings is not recommended as wrapping bruised areas with elastic bandages can cause additional pressure and potentially worsen bruising or bleeding.
C. While dietary modifications may be necessary for other reasons, removing cold and frozen foods does not address the immediate risk of bleeding associated with low platelet counts.
D. This is crucial because patients with thrombocytopenia are at an increased risk of bleeding, which may not always be visible or apparent. Regular monitoring can help in early detection and prompt management of any bleeding episodes.
Correct Answer is A
Explanation
A. A right foot that is pale with sluggish capillary refill suggests compromised circulation, possibly due to compartment syndrome, and requires immediate intervention to prevent tissue damage.
B. Circumferential edema of the right foot may be expected after a fracture and casting but does not indicate an immediate complication requiring intervention.
C. Reports of throbbing right leg pain are common after a fracture and casting and may be managed with appropriate pain medication but do not necessarily indicate an immediate complication.
D. An increased temperature to the lower extremity may be indicative of inflammation but does not necessarily require immediate intervention unless accompanied by other signs of infection or complications.
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