A nurse is teaching a client who has esophageal cancer and is scheduled to start radiation therapy. Which of the following instructions should the nurse include in the teaching?
Use a washcloth to bathe the treatment area.
Remove the dye markings after each radiation treatment.
Avoid sun exposure from 1100 to 1600.
Wear clothing over the area of radiation treatment.
The Correct Answer is A
Choice A reason: Clients receiving radiation therapy should use gentle methods to clean the treatment area, such as a soft washcloth, to avoid irritating the skin. The skin in the treatment field is highly sensitive and prone to breakdown, so gentle care is essential.
Choice B reason: Dye markings are used to guide radiation therapy and must remain intact throughout the course of treatment. Removing them would interfere with accurate targeting of the radiation beam.
Choice C reason: While avoiding sun exposure is generally good advice, the specific instruction for radiation therapy is to protect the treatment area from trauma and irritation. Sun avoidance is important, but the more direct teaching point is gentle cleansing.
Choice D reason: Clothing should not rub or irritate the treatment area. Loose, soft clothing is recommended, but simply wearing clothing over the area is not the key teaching point. The priority is protecting the skin from irritation and maintaining the markings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Massaging the area of a pressure ulcer is contraindicated. Massage can damage fragile capillaries and tissues, worsening the ulcer and increasing the risk of further breakdown. It may also cause pain and inflammation. Therefore, this intervention is inappropriate for a stage II ulcer.
Choice B reason: An alternating pressure mattress is an evidence-based intervention that helps redistribute pressure across the body and reduces the risk of further skin breakdown. For a comatose client who cannot reposition themselves, this intervention is especially important. It promotes circulation and prevents worsening of the ulcer, making it the most appropriate choice.
Choice C reason: A sterile, dry gauze dressing is not the recommended treatment for a stage II ulcer. Stage II ulcers involve partial-thickness skin loss and require a moist wound environment to promote healing. Dry gauze can adhere to the wound bed, cause trauma during removal, and delay healing. Moist dressings such as hydrocolloids or foam dressings are preferred.
Choice D reason: Donut-shaped cushions are not recommended because they concentrate pressure around the wound edges, worsening ischemia and tissue damage. They can increase the risk of ulcer progression rather than prevent it. This intervention is inappropriate for pressure ulcer management.
Correct Answer is B
Explanation
Choice A reason: Heat should not be applied during the first 24 hours after a sprain because it increases blood flow and swelling. Cold therapy (ice packs) is recommended initially to reduce inflammation. This option is incorrect.
Choice B reason: Wrapping the affected extremity with a compression dressing is part of the RICE protocol (Rest, Ice, Compression, Elevation), which is the standard treatment for sprains. Compression helps reduce swelling and provides support. This is the correct answer.
Choice C reason: Acetaminophen is effective for pain but does not reduce inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen are preferred for managing both pain and inflammation in sprains. Therefore, this option is incorrect.
Choice D reason: Advising the client to begin walking 4 hours after the injury is unsafe. Early ambulation can worsen tissue damage and swelling. Rest is recommended initially, followed by gradual weight-bearing as tolerated. This option is incorrect.
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