The nurse is teaching a client with cancer about skincare 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 rationale:
Applying prescribed lotions to the radiation site is generally a recommended part of skin care during radiation therapy, as it helps keep the skin moisturized and reduces irritation.
Choice B rationale:
Washing the radiation site with antibacterial soap and water is not recommended. Clients undergoing radiation therapy are typically advised to use gentle, mild soaps and to avoid scrubbing or using harsh cleansers on the treated area. Antibacterial soap may be too harsh and could lead to skin irritation.
Choice C rationale:
Wearing clothing to cover the radiation site is a good practice to protect the area from sun exposure and potential irritation.
Choice D rationale:
Drying the area with patting motions after taking a shower is the correct way to dry the radiation site, as it minimizes friction and reduces the risk of skin damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale:
Restricting visitors to family members only may not necessarily be a beneficial intervention and could potentially isolate the client further, which may not be in their best interest.
Choice B rationale:
Discussing the client's suicide plan is essential to assess the level of risk and develop strategies to keep the client safe. It allows the healthcare team to understand the severity of the client's depressive symptoms and potential suicidal ideation.
Choice C rationale:
Limiting the time allowed to play video games may be a consideration in a broader plan of care, but it is not a primary intervention for addressing depression in adolescents. The focus should be on safety, communication, and building a therapeutic relationship.
Choice D rationale:
Encouraging the client to discuss thoughts and feelings about wanting to die is crucial for therapeutic communication and assessment. It provides an opportunity for the client to express their emotions and allows for intervention and support.
Choice E rationale:
Reinforcing statements regarding a will to live and realistic plans for the future is important for building hope and motivation in the client. It can be part of a positive, strengths-based approach to treatment.
Correct Answer is ["E","F","H"]
Explanation
Choice A rationale:
This order is useful to evaluate the client's electrolyte levels, renal function, and acid-base balance, as she has ERSD and missed her dialysis session. She may have hyperkalemia, metabolic acidosis, or uremia, which can affect her cardiac and neurological status.
Choice B rationale:
This order is helpful to assess the client's cardiac structure and function, as she has a history of CAD and HTN and may have developed heart failure or valvular disease.
Choice C rationale:
This order is beneficial to rule out any intra-abdominal causes of the client's nausea and poor appetite, such as infection, obstruction, or bleeding.
Choice D rationale:
This order is necessary to identify any possible source of infection or sepsis, as the client has been ill for 3 days and has a history of diabetes, which can impair her immune system.
Choice E rationale:
This order is important to assess the client's cardiac and pulmonary status, as she has a history of CAD and is presenting with chest discomfort and lightheadedness, which could indicate a cardiac event or pulmonary edema.
Choice F rationale:
This order is essential to monitor the client's heart rate and rhythm, as she has a history of CAD and HTN and is at risk for arrhythmias, ischemia, and infarction.
Choice G rationale:
This order is important to evaluate the client's hematological status, as she has ERSD and may have anemia, leukocytosis, or thrombocytopenia.
Choice H rationale:
This order is crucial to obtain a baseline of the client's cardiac electrical activity and to detect any signs of acute coronary syndrome, such as ST-segment elevation or depression, T wave inversion, or Q waves.
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