A nurse is caring for an 8-year-old child who is experiencing dry skin due to radiation therapy. Which of the following actions should the nurse suggest?
Remove the skin markings following radiation.
Apply lotions liberally to the skin.
Wear protective clothing when outside.
Cleanse skin with an antibacterial cleanser.
The Correct Answer is C
A. Remove the skin markings following radiation: Skin markings should not be removed during radiation therapy, as they are necessary for accurate targeting of radiation. Removing them can interfere with treatment accuracy and is not recommended.
B. Apply lotions liberally to the skin: While moisturizing can help with dryness, during radiation therapy, the nurse should recommend only mild, non-irritating, fragrance-free lotions approved by the radiation team. Applying products liberally or unapproved lotions can interfere with radiation dosing.
C. Wear protective clothing when outside: Radiation can make the skin more sensitive to sunlight. Wearing protective clothing and using sun protection helps prevent additional irritation, burns, or damage to already vulnerable skin. This is an appropriate measure to manage skin integrity.
D. Cleanse skin with an antibacterial cleanser: Antibacterial or harsh cleansers can irritate the sensitive skin of a child undergoing radiation therapy. Gentle, mild, fragrance-free soap and lukewarm water are preferred to maintain skin integrity without causing further damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Administer calcium gluconate for urine output less than 50 mL/hr: Calcium gluconate is given to treat magnesium sulfate toxicity, which is indicated by absent deep tendon reflexes, respiratory depression, or high serum magnesium levels. Low urine output requires monitoring but does not automatically warrant calcium gluconate administration.
B. Check deep tendon reflexes every 8 hr: Deep tendon reflexes should be assessed frequently during magnesium sulfate therapy, usually every 1–2 hours, to detect early signs of toxicity. Checking only every 8 hours is insufficient for safe monitoring.
C. Administer one dose of betamethasone now and repeat in 24 hr: Betamethasone is given to accelerate fetal lung maturity in preterm gestation, which is critical at 31 weeks. Administering the two-dose course as prescribed helps reduce neonatal respiratory complications, making this a priority intervention alongside magnesium sulfate therapy.
D. Limit IV intake to no more than 200 mL/hr: Monitoring and limiting IV fluids helps prevent fluid overload and pulmonary edema in preeclamptic clients, but ensuring fetal lung maturity with betamethasone takes priority at this gestational age in case of an early delivery.
Correct Answer is C
Explanation
A. The client's high-density lipoprotein level has increased: While metformin can have minor effects on lipid metabolism, an increase in HDL is not the primary therapeutic goal or a direct measure of the medication’s effectiveness in managing type 2 diabetes.
B. The client's frequency of incontinence has decreased: Urinary incontinence is not a direct indicator of metformin effectiveness. Changes in incontinence may result from other conditions or medications and do not reflect glycemic control.
C. The client's HbA1c has decreased: A decrease in HbA1c indicates improved long-term blood glucose control, which is the primary goal of metformin therapy. Monitoring HbA1c over 2–3 months helps determine how effectively the medication is managing type 2 diabetes.
D. The client's iron level has increased: Iron levels are not affected by metformin and do not serve as a measure of its efficacy. Changes in iron would be related to dietary intake, absorption issues, or other medical conditions rather than glucose management.
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