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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
"I should discuss this document with my family after I sign it"
Advance directives are legal documents that allow an individual to specify the type of medical care they want to receive in case they become unable to make their own decisions. It is important for the client to discuss their wishes with their family members or loved ones so that they are aware of the client's desires and can act accordingly in case of an emergency.
"I am not allowed to change my mind once I sign this document" is incorrect. The client can change their mind about their advance directive at any time and for any reason. It is important for the client to review their advance directive periodically and make changes as necessary.
"An attorney will need to notarize this document for it to be valid" is also incorrect. While some states require advance directives to be notarized or witnessed, not all states do. It is important for the client to check with their state's laws regarding advance directives to ensure that their document is legally binding.
"My partner needs to be present when I sign this document" is not necessarily true. While it is recommended for the client to have a witness present when signing their advance directive, it does not have to be their partner. The witness should be someone who is not a family member, healthcare provider, or beneficiary of the client's estate.
Correct Answer is A
Explanation
Wash hands with soap and water for 20 seconds: Washing hands with soap and water is the preferred method for hand hygiene in most situations, especially when hands are visibly soiled or contaminated with body fluids. The CDC recommends washing hands for at least 20 seconds, ensuring that all surfaces of the hands, including the back of the hands, between the fingers, and under the nails, are thoroughly cleaned.
Artificial nails should not be worn when performing direct client care: Artificial nails, including nail extensions and overlays, should be avoided when providing direct client care. The wearing of
artificial nails can increase the risk of bacterial colonization and make proper hand hygiene more challenging. Short, natural nails without nail polish are recommended for healthcare workers to ensure effective hand hygiene and reduce the risk of infection transmission.
Wear sterile gloves when in contact with body fluids: Sterile gloves are indicated when there is a need for an aseptic technique or when in contact with sterile body sites or invasive procedures.
However, for routine patient care and non-sterile procedures, non-sterile disposable gloves are typically sufficient. The use of gloves does not replace the need for proper hand hygiene before and after glove use.
Use alcohol-based cleanser when hands are visibly soiled: Alcohol-based hand sanitizers are effective in killing many types of germs when used correctly. However, they are not as effective when hands are visibly soiled or contaminated with body fluids. In such cases, washing hands with soap and water is recommended to ensure proper cleansing and removal of visible dirt or contaminants.
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