Which instruction is most important for the nurse to provide a client who is receiving radiation therapy for lung cancer when teaching about skin care?

ice packs may be applied to the site for 30 minutes every hour for comfort

Incorporate rest periods throughout the day

Do not share bathrooms/toilets with others for 48 hours after treatment

Wear loose, soft clothing over the treated area

Answer and Explanation

The Correct Answer is D

A) Ice packs may be applied to the site for 30 minutes every hour for comfort:
This is not an appropriate recommendation for skin care related to radiation therapy. Applying ice packs to the skin can cause vasoconstriction and might worsen skin irritation or damage from radiation. Instead, the patient should be advised to avoid extreme temperatures, including hot or cold compresses, which could exacerbate skin issues in the radiation field.

B) Incorporate rest periods throughout the day:
While rest is important for overall well-being during radiation therapy, this instruction does not directly address the skin care needs associated with radiation. The primary concern with radiation therapy is protecting the skin from further irritation and damage, so specific skin care measures are more crucial in this context than general rest periods.

C) Do not share bathrooms/toilets with others for 48 hours after treatment:
This instruction is not necessary for most patients undergoing radiation therapy, especially for lung cancer. The concern about not sharing bathrooms or toilets generally applies to patients receiving brachytherapy or radioactive implants, where radiation is placed inside the body. For external radiation, there is no risk of contamination through shared bathroom use.

D) Wear loose, soft clothing over the treated area:
This is the most appropriate instruction for skin care during radiation therapy. Radiation therapy can cause the skin to become tender, red, and irritated, so wearing loose, soft clothing will help minimize friction and pressure on the skin. Tight or rough clothing can irritate the radiation site, increasing the risk of skin breakdown. Loose, breathable fabrics like cotton can help keep the skin comfortable and allow it to heal while protecting it from further damage.

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Correct Answer is A

Explanation

A) Urine output of 0.5-1 mL/kg/hr:
This is a positive outcome during fluid resuscitation for burn patients. Adequate urine output is a key indicator of proper renal perfusion and fluid balance. A urine output of 0.5-1 mL/kg/hr is considered optimal for burn patients during the first 24-48 hours of resuscitation. It suggests that the kidneys are receiving sufficient blood flow and that the patient is responding appropriately to the fluids being administered.

B) Serum sodium level 149 mEq/L (normal 135-145):
A serum sodium level of 149 mEq/L is high and indicates hypernatremia, which is a common complication of excessive fluid resuscitation, particularly with the use of crystalloids. Hypernatremia can lead to cerebral edema, altered mental status, and other severe complications. Therefore, this finding would suggest improper fluid management and would not be considered a positive outcome.

C) Blood pressure 82/54:
A blood pressure of 82/54 is hypotensive, which is concerning in a burn patient. Hypotension indicates inadequate tissue perfusion, potentially leading to shock and organ failure. While low blood pressure may occur in the initial stages of resuscitation due to the rapid shifts in fluid, a sustained low blood pressure is not a positive outcome.

D) Heart rate 124 beats per minute:
A heart rate of 124 beats per minute is tachycardic and suggests that the patient is compensating for hypovolemia or inadequate circulatory volume, possibly due to insufficient fluid resuscitation. Although an elevated heart rate may occur as a compensatory mechanism in the initial stages of burn resuscitation, sustained tachycardia indicates ongoing volume depletion or inadequate perfusion and is not an ideal outcome.

A. respiratory acidosis B. metabolic acidosis C. metabolic alkalosis D. respiratory alkalosis

Correct Answer is D

Explanation

A) Respiratory acidosis:
Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2) in the blood, leading to a decrease in pH. In the given blood gas values, the PaCO2 is 28 mmHg, which is lower than the normal range (35-45 mmHg), indicating that CO2 is being exhaled more than usual, not accumulating.

B) Metabolic acidosis:
Metabolic acidosis results from a decrease in bicarbonate (HCO3-) or an increase in acid in the body. However, in the provided values, the bicarbonate (HCO3-) is normal at 24 mEq/L, and the pH is elevated at 7.51, indicating alkalosis rather than acidosis

C) Metabolic alkalosis:
Metabolic alkalosis occurs when there is an increase in bicarbonate levels or excessive loss of acids, often associated with vomiting or diuretic use. However, in this case, the bicarbonate level (HCO3-) is normal, and the pH is more consistent with alkalosis due to respiratory factors, not metabolic causes.

D) Respiratory alkalosis:
Respiratory alkalosis occurs when there is excessive exhalation of CO2, leading to a rise in blood pH (alkalosis). The pH is 7.51, which is above the normal range (7.35-7.45), indicating alkalosis. Additionally, the PaCO2 is low at 28 mmHg, which suggests that the client is hyperventilating and exhaling too much CO2, confirming respiratory alkalosis as the correct interpretation.

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Which instruction is most important for the nurse to provide a client who is receiving radiation therapy for lung cancer when teaching about skin care?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for patient with severe, major burns who is receiving fluid resuscitation per protocol. Which of the following assessments indicate positive outcome?

Correct Answer is A

Explanation

The client's arterial blood gases reveal the following results; pH 7.51. PaO2 80 mmHg, PaCO2 28 mmHg, HCO3-24 mEq/L. 02 saturation 92%. The nurse interprets this blood gas result as

Correct Answer is D

Explanation

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