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.”

Answer and Explanation

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.

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Correct Answer is A

Explanation

Rationale:

A. Clarify the source of the referral: Before taking any action, the nurse must first clarify the referral source to understand why the visit is needed, the client’s health status, and any specific concerns or priorities. This ensures the nurse has accurate and complete information to plan the visit safely and effectively.

B. Contact the family by phone: While contacting the family is necessary to arrange the visit, it should occur only after the nurse understands the purpose of the referral and any special considerations to communicate relevant information.

C. Implement the nursing process: Implementing the nursing process requires assessment and planning. The nurse cannot proceed to intervention without first obtaining information about the referral and preparing appropriately.

D. Schedule a time for the home visit: Scheduling is important for logistics, but it should occur after clarifying the referral and understanding the family’s needs to ensure the visit is purposeful and safe.

A. Remove the client's catheter. B. Prepare the client for chest tube insertion. C. Place the client in a left-lateral Trendelenburg position D. Instruct the client to perform the Valsalva maneuver.

Correct Answer is C

Explanation

Rationale:

A. Remove the client's catheter: Removing the catheter could allow more air to enter the circulation and worsen the embolism. The priority is to prevent further air entry while stabilizing the client, not immediate removal of the line.

B. Prepare the client for chest tube insertion: Chest tubes are used for pneumothorax or pleural effusions, not for treating an air embolism. Immediate positioning and oxygen therapy are the primary interventions.

C. Place the client in a left-lateral Trendelenburg position: Positioning the client in the left-lateral Trendelenburg (head down, left side down) traps air in the right atrium and prevents it from entering the pulmonary circulation, reducing cardiovascular compromise. This is the recommended first intervention for a suspected air embolism.

D. Instruct the client to perform the Valsalva maneuver: Performing the Valsalva maneuver increases intrathoracic pressure and may temporarily help, but it is not the first priority. Proper positioning and immediate oxygen administration are more critical to prevent complications.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

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?

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Explanation

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Explanation

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