A nurse is teaching a client who is receiving radiation therapy about skin protection. Which of the following client statements indicates an understanding of the teaching?
"I will expose the irradiated area of skin to the sun for no more than 30 minutes per day."
"I will apply my favorite unscented lotion to the irradiated area of skin twice each day."
"I will use my hand instead of a washcloth to wash the irradiated area of skin."
"I will make sure I have sterile water to wash the irradiated area of skin.”
The Correct Answer is C
Rationale:
A. "I will expose the irradiated area of skin to the sun for no more than 30 minutes per day.": Skin that has been irradiated is highly sensitive to sunlight, and any direct exposure can increase the risk of burns and further damage. Clients should avoid sun exposure entirely on affected areas.
B. "I will apply my favorite unscented lotion to the irradiated area of skin twice each day.": Applying lotion may be appropriate if recommended by the radiation oncology team, but the client should avoid using any lotion, cream, or ointment not approved for use on irradiated skin, as some products can irritate the area.
C. "I will use my hand instead of a washcloth to wash the irradiated area of skin.": Using the hand is the safest method for cleansing irradiated skin, as washcloths can cause friction, irritation, or breakdown. Gentle washing helps protect fragile skin and prevent injury during radiation therapy.
D. "I will make sure I have sterile water to wash the irradiated area of skin.": Sterile water is not required for routine skin care of irradiated areas. Mild soap and lukewarm tap water are typically sufficient unless the provider specifies otherwise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
Rationale for correct choices
• Right lower extremity +2 edema from ankle to below knee: This level of edema in one limb suggests impaired venous return and is a key indicator of possible deep vein thrombosis. Unilateral swelling that develops with reduced mobility places the client at higher risk and warrants immediate assessment. Early detection is important to prevent progression to pulmonary embolism.
• Skin warm and inflamed on right lower extremity: Localized warmth and inflammation are hallmark findings of venous thrombosis or inflammatory processes in the limb. The client’s sedentary pattern and unilateral symptoms strengthen the suspicion of a vascular complication. Prompt evaluation helps guide diagnostic testing such as Doppler ultrasound.
• Slight limp with weight bearing on right extremity: A new limp combined with swelling and inflammation suggests evolving pain or functional impairment. This may indicate deep venous obstruction, localized inflammation, or injury exacerbated by reduced mobility.
Rationale for incorrect choices
• Client is awake, alert, oriented x3: This indicates intact neurological status and does not require follow-up at this time. The client shows no evidence of cognitive changes, syncope, or neurological compromise.
• Client reports no palpitations, heart rhythm regular: A regular heart rhythm without palpitations suggests stable cardiovascular status. There are no immediate arrhythmia-related concerns requiring follow-up.
Correct Answer is C
Explanation
Rationale:
A. Change a dressing on an implanted central venous access device: This is a sterile procedure that requires assessment skills and knowledge of infection control. It must be performed by a licensed nurse, not an assistive personnel (AP).
B. Suction a new tracheostomy: Suctioning a new tracheostomy is a high-risk procedure requiring specialized knowledge to prevent hypoxia or trauma. Only a licensed nurse should perform this intervention.
C. Perform postmortem care: Postmortem care is within the scope of practice for an AP. It involves cleansing, positioning, and preparing the body for the family or mortuary, and does not require advanced clinical judgment or sterile technique.
D. Remove an NG tube: Removal of a nasogastric tube requires assessment and understanding of client tolerance and potential complications, which are responsibilities of a licensed nurse. It is not appropriate to delegate this task to an AP.
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