The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?
Applies prescribed lotions to the radiation site.
Washes the radiation site with antibacterial soap and water.
Wears clothing to cover the radiation site.
Dries the area with patting motions after taking a shower.
The Correct Answer is B
Choice A reason: Applying prescribed lotions to the radiation site is a good action for a client with cancer receiving external beam radiation, because it can help moisturize and protect the skin from irritation and breakdown. The client should follow the instructions of the health care provider regarding the type and frequency of lotion application. Therefore, this choice does not indicate a need for further teaching.
Choice B reason: Washing the radiation site with antibacterial soap and water is a bad action for a client with cancer receiving external beam radiation, because it can cause dryness, inflammation, and infection of the skin. The client should use mild soap and water or saline solution to gently cleanse the area without rubbing or scrubbing. Therefore, this choice indicates a need for further teaching.
Choice C reason: Wearing clothing to cover the radiation site is a good action for a client with cancer receiving external beam radiation, because it can help shield the skin from sun exposure and friction. The client should wear loose-fitting, soft, cotton clothing that does not irritate or constrict the area. Therefore, this choice does not indicate a need for further teaching.
Choice D reason: Drying the area with patting motions after taking a shower is a good action for a client with cancer receiving external beam radiation, because it can help prevent trauma and infection of the skin. The client should avoid rubbing or scratching the area or using hair dryers or heating pads on it. Therefore, this choice does not indicate a need for further teaching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Canned vegetables with additional table salt are not a good choice for someone with cholecystitis, because they are high in sodium, which can increase fluid retention and inflammation. However, this choice is not eliminated by the client, so it does not indicate successful teaching.
Choice B reason: Pasta with herbal butter and no meat sauce is a good choice for someone with cholecystitis, because it is low in fat and protein, which can trigger gallbladder contractions and pain. This choice is not eliminated by the client, so it does not indicate successful teaching.
Choice C reason: Citrus fruit and melon with a salt substitute are also good choices for someone with cholecystitis, because they are high in vitamin C and water, which can help dissolve gallstones and prevent infection. This choice is not eliminated by the client, so it does not indicate successful teaching.
Choice D reason: Whole milk and daily servings of ice cream are bad choices for someone with cholecystitis, because they are high in fat and cholesterol, which can worsen gallbladder inflammation and increase the risk of gallstone formation. This choice is eliminated by the client, so it indicates successful teaching.
Correct Answer is C
Explanation
Choice A reason: A referral for social services at home is not necessary for a client with Addison's disease who has stable vital signs, adequate hydration, and good self-care knowledge.
Choice B reason: Limiting daily fluid intake to 500 mL is not appropriate for a client with Addison's disease, who is at risk of dehydration and hypotension. The client should drink fluids according to thirst and urine output.
Choice C reason: Preparing the client for discharge home is the best action for the nurse to implement, as the client has no signs of complications or deterioration from Addison's disease. The client should be able to manage the condition at home with regular follow-up and medication adherence.
Choice D reason: Strict intake and output monitoring is not required for a client with Addison's disease who has normal blood pressure, moist mucous membranes, and strong peripheral pulses. These indicate adequate fluid balance and renal function.
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