A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?
Do not apply heat to the area of irradiation.
Use an antibiotic ointment to treat skin breakdown.
Lubricate the skin with hypoallergenic lotion.
Do not wash the area of irradiation.
The Correct Answer is A
Choice A: Do not apply heat to the area of irradiation. This instruction is correct and should be included in the teaching. Applying heat to the area of irradiation can increase inflammation, pain, or burning sensation on the skin. The client should avoid heat sources such as hot water, heating pads, or sun exposure in the area of irradiation.
Choice B: Use an antibiotic ointment to treat skin breakdown. This instruction is not correct and should not be included in the teaching. Using an antibiotic ointment to treat skin breakdown can cause allergic reactions, infection, or interference with radiation therapy. The client should consult with her provider before using any topical products in the area of irradiation.
Choice C: Lubricate the skin with hypoallergenic lotion. This instruction is not correct and should not be included in the teaching. Lubricating the skin with hypoallergenic lotion can cause irritation, infection, or interference with radiation therapy. The client should avoid applying any lotions, creams, or oils on the area of irradiation unless prescribed by her provider.
Choice D: Do not wash the area of irradiation. This instruction is not correct and should not be included in the teaching. Washing the area of irradiation can help prevent infection, remove dead skin cells, and reduce odor. The client should wash the area of irradiation gently with mild soap and water, pat it dry, and avoid rubbing or scrubbing.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: "Don't worry, I will be with you during the exam." This response is not appropriate because it does not address the client's feelings or concerns. It also may sound dismissive or patronizing to the client, who may have valid reasons to be nervous.
Choice B: "What part of the exam makes you most nervous?" This response is appropriate because it shows empathy and interest in the client's perspective. It also invites the client to express her fears or questions and allows the nurse to provide information and reassurance.
Choice C: "All you need to do is relax." This response is not appropriate because it does not acknowledge the client's feelings or concerns. It also may sound unrealistic or insensitive to the client, who may find it hard to relax in a stressful situation.
Choice D: "A pelvic exam is required if you want birth control pills." This response is not appropriate because it does not address the client's feelings or concerns. It also may sound coercive or threatening to the client, who may feel pressured or intimidated by the requirement.
Correct Answer is ["C","D","E"]
Explanation
Choice A reason: Baby oil is not an acceptable lubricant, as it can damage the condom and reduce its effectiveness. The students should use water-based or silicone-based lubricants instead.
Choice B reason: Ensuring a tight fit of the condom is not advisable, as it can cause discomfort and increase the risk of breakage. The students should leave some space at the tip of the condom to collect semen and prevent spillage.
Choice C reason: Only using latex condoms is correct, as they are more effective than other materials in preventing pregnancy and sexually transmitted infections. The students should avoid using condoms made of natural skin or lambskin, as they are porous and can allow viruses to pass through.
Choice D reason: Placing the condom on an erect penis is correct, as it ensures proper application and prevents slippage. The students should unroll the condom over the entire length of the penis before any sexual contact.
Choice E reason: Storing the condoms in a cool dry place is correct, as it prevents exposure to heat, moisture, sunlight, or sharp objects that can damage the condom. The students should check the expiration date and integrity of the condom before use.
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