The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

Applies prescribed lotions to the radiation site.

Washes the radiation site with antibacterial soap and water.

Wears clothing to cover the radiation site.

Dries the area with patting motions after taking a shower.

Answer and Explanation

The Correct Answer is B

Choice A reason: Applying prescribed lotions to the radiation site is a good action for a client with cancer receiving external beam radiation, because it can help moisturize and protect the skin from irritation and breakdown. The client should follow the instructions of the health care provider regarding the type and frequency of lotion application. Therefore, this choice does not indicate a need for further teaching.

Choice B reason: Washing the radiation site with antibacterial soap and water is a bad action for a client with cancer receiving external beam radiation, because it can cause dryness, inflammation, and infection of the skin. The client should use mild soap and water or saline solution to gently cleanse the area without rubbing or scrubbing. Therefore, this choice indicates a need for further teaching.

Choice C reason: Wearing clothing to cover the radiation site is a good action for a client with cancer receiving external beam radiation, because it can help shield the skin from sun exposure and friction. The client should wear loose-fitting, soft, cotton clothing that does not irritate or constrict the area. Therefore, this choice does not indicate a need for further teaching.

Choice D reason: Drying the area with patting motions after taking a shower is a good action for a client with cancer receiving external beam radiation, because it can help prevent trauma and infection of the skin. The client should avoid rubbing or scratching the area or using hair dryers or heating pads on it. Therefore, this choice does not indicate a need for further teaching.

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Correct Answer is C

Explanation

Choice A reason: Restriction of caloric intake is not a good change for a client with diabetes mellitus and an upper respiratory infection, because it can lead to hypoglycemia and malnutrition. The client needs adequate calories to maintain blood glucose levels and support immune function. Therefore, this choice is incorrect.

Choice B reason: Fewer fingerstick glucose checks are not a good change for a client with diabetes mellitus and an upper respiratory infection, because they can lead to poor blood glucose control and complications. The client needs frequent monitoring of blood glucose levels to adjust insulin doses and prevent hyperglycemia or hypoglycemia. Therefore, this choice is incorrect.

Choice C reason: Higher doses of insulin are a good change for a client with diabetes mellitus and an upper respiratory infection, because they can help lower blood glucose levels and prevent ketoacidosis. The client needs more insulin to overcome the increased insulin resistance caused by the infection and the stress hormones. Therefore, this choice is correct.

Choice D reason: Increased oral fluid intake is a good change for a client with diabetes mellitus and an upper respiratory infection, but it is not directly related to blood glucose management. The client needs more fluids to prevent dehydration and clear mucus from the respiratory tract. Therefore, this choice is not the best answer.

A. Weight gain of 2 pounds (0.91 kg) in one day. B. Fremitus over the chest wall. C. Serum sodium of 150 mEq/L (150 mmol/L). D. Urine specific gravity of 1.004.

Correct Answer is A

Explanation

Choice A reason: Weight gain of 2 pounds (0.91 kg) in one day is a sign of fluid retention, which occurs in SIADH due to excessive secretion of antidiuretic hormone (ADH). ADH causes the kidneys to reabsorb water and reduce urine output, leading to hyponatremia and hypervolemia.

Choice B reason: Fremitus over the chest wall is a sign of increased vibration or air movement in the lungs, which can indicate pneumonia, bronchitis, or pleural effusion. These are not related to SIADH, but may be complications of head injury or fluid overload.

Choice C reason: Serum sodium of 150 mEq/L (150 mmol/L) is a sign of hypernatremia, which is a high level of sodium in the blood. This is the opposite of what happens in SIADH, where sodium levels are low due to dilution by excess water.

Choice D reason: Urine specific gravity of 1.004 is a sign of diluted urine, which indicates low concentration of solutes in the urine. This is also the opposite of what happens in SIADH, where urine is concentrated and has a high specific gravity.

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The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the client expect?

Correct Answer is C

Explanation

A client with a closed head injury demonstrates signs of syndrome of inappropriate antidiuretic hormone (SIADH). Which additional finding should the nurse expect to obtain?

Correct Answer is A

Explanation

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