A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck.

Which of the following instructions should the nurse include in the teaching?

Avoid exposing the neck to the cold.

Eat three large meals each day.

Cleanse the neck by rubbing with a washcloth.

Limit fluid intake to 750 mL per day.

Answer and Explanation

The Correct Answer is A

Radiation therapy can cause increased sensitivity and dryness in the skin. Exposing the neck to cold temperatures may exacerbate these symptoms and potentially lead to discomfort or skin damage. Encourage the client to keep the neck covered and warm, especially when going outside in cold weather.

While proper nutrition is important during radiation therapy, the specific instruction to eat three large meals each day is not necessarily applicable or beneficial. It is generally recommended to have a balanced and nutritious diet, which may include smaller, frequent meals or snacks if the client's appetite is affected.

During radiation therapy, the skin in the treatment area can become sensitive and prone to irritation. Rubbing the neck vigorously with a washcloth can further irritate the skin. Instead, advise the client to gently cleanse the neck using a mild, non-irritating soap and patting the skin dry with a soft towel.

While radiation therapy can cause certain side effects, such as dry mouth or difficulty swallowing, it is generally not necessary to restrict fluid intake unless specifically advised by the healthcare provider. Adequate hydration is important for overall health and well-being, and the client should be encouraged to drink enough fluids unless instructed otherwise.

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Correct Answer is D

Explanation

Herpes simplex is primarily transmitted through direct contact with the skin or mucous membranes of an infected individual. Contact precautions are designed to prevent the spread of microorganisms that are transmitted by direct contact or indirect contact with contaminated surfaces. These precautions include wearing gloves and a gown when entering the client's room, ensuring proper hand hygiene, and using dedicated equipment for the client.

Droplet precautions are used for infections that are transmitted through respiratory droplets generated by coughing, sneezing, or talking, such as influenza or pertussis.

Airborne precautions are used for infections that are transmitted by smaller droplet nuclei that can remain suspended in the air for longer periods, such as tuberculosis or measles.

Protective environment is a specialized isolation precaution used for clients with compromised immune systems, such as those undergoing stem cell transplantation, and involves strict control of the environment to reduce the risk of acquiring infections.

A. Triiodothyronine B. Blood urea nitrogen C. Arterial blood gases D. Prothrombin time

Correct Answer is D

Explanation

Warfarin is an anticoagulant medication that works by inhibiting the synthesis of vitamin K-dependent clotting factors in the liver. Therefore, it is important to monitor the client's clotting ability to ensure that the medication is working properly and not causing any adverse eﬀects. The laboratory test that is used to monitor warfarin therapy is the prothrombin time (PT), which measures the time it takes for the blood to clot. The nurse should monitor the client's PT regularly and adjust the dosage of warfarin as necessary to maintain the therapeutic range. Option a (Triiodothyronine) is a thyroid hormone and is not directly related to warfarin therapy. Option b (Blood urea nitrogen) is a measure of kidney function and is also not directly related to warfarin therapy. Option c (Arterial blood gases) is a measure of oxygen and carbon dioxide levels in the blood and is not related to warfarin therapy.

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A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck. Which of the following instructions should the nurse include in the teaching?

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A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck.

Which of the following instructions should the nurse include in the teaching?