Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer?

Protect the site from getting wet during bathing.

Gently pat the skin dry after rinsing with water.

Frequently apply moisturizers to prevent dry skin.

Use a sponge to debride the affected area.

Answer and Explanation

The Correct Answer is B

A. Protect the site from getting wet during bathing. While it is important to avoid prolonged soaking, gentle rinsing with water is usually allowed. Complete avoidance of water is not typically necessary. Gentle bathing is important for hygiene.

B. Gently patting the skin dry after rinsing with water is a good practice as it helps to minimize friction and irritation to the sensitive skin. Rubbing or scrubbing the skin should be avoided.

C. Applying moisturizers to prevent dry skin can be beneficial for overall skin health, but it is important to consult with the healthcare team and follow specific instructions regarding the use of moisturizers during radiation therapy. Certain types of moisturizers or creams may interfere with the radiation treatment or cause skin irritation. Frequent application is not always necessary. Over-hydration can soften the skin and increase vulnerability.

D. Using a sponge to debride the affected area is not recommended during radiation therapy. The skin in the radiation treatment field is already sensitive and prone to damage, and using a sponge for debridement can further traumatize the skin. It is important to avoid any abrasive or rough handling of the treated skin.

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Correct Answer is D

Explanation

The correct answer is choice D: Begin chest compressions at 100/minute.

Choice A rationale:

Observing for swelling at the fracture site is not immediately relevant in this emergency situation. The priority is to address the lack of pulse and respiration.

Choice B rationale:

Analyzing the cardiac rhythm in another lead is unnecessary when the patient has no pulse and is not breathing. Immediate life-saving measures are required.

Choice C rationale:

Obtaining a 12-lead electrocardiogram is not the priority in this scenario. The patient needs immediate resuscitation efforts.

Choice D rationale:

Beginning chest compressions at 100/minute is the correct intervention. The absence of a carotid pulse and spontaneous respirations indicates cardiac arrest, and chest compressions are essential to maintain circulation and oxygenation until further help arrives.

A. Ortolani maneuver causing a click at the hip joint. B. Plumb line test indicates fetal position curvature. C. Babinski test that reveals fanning out of toes. D. Moro test precipitating a startle response.

Correct Answer is A

Explanation

The Ortolani maneuver is a physical examination technique used to assess for developmental dysplasia of the hip (DDH) in newborns. During the maneuver, the nurse gently abducts the infant's hips and applies gentle pressure to detect any instability or "click" at the hip joint. A positive Ortolani maneuver, where a click or clunk is felt or heard, can indicate the presence of a hip dislocation or dysplasia.

Asymmetrical buttocks can be a sign of hip dysplasia in newborns, and a positive Ortolani maneuver is an important finding that suggests a potential hip joint problem. Reporting this assessment test result to the healthcare provider allows for further evaluation and appropriate management of the newborn's hip condition.

The Plumb line test, which assesses fetal position curvature, is not directly related to hip dysplasia and may not be significant in this context.

The Babinski test, which reveals fanning out of the toes, is used to assess the integrity of the infant's neurological system and is not specific to hip dysplasia.

The Moro test, also known as the startle response, is a reflex assessment used to evaluate the newborn's neurological and sensory function. While it is important to assess the overall neurological status of the newborn, the Moro test is not specific to hip dysplasia.

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Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?

Correct Answer is D

Explanation

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider?

Correct Answer is A

Explanation

Exhibits here Review H and P. What factors are important in determining the level of hypoxemia that the child may have experienced during the submersion? Select all that apply.

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider?

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?

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