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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E","F","G"]
Explanation
A. Incorrect- 0200: This is not a scheduled time for vital sign assessments every 4 hours.
B. Correct- 1300: This is 4 hours after the 0900 vital signs, following the every 4-hour schedule.
C. Correct 1000: This is 4 hours after the 0600 vital signs, following the every 4-hour schedule.
D. Correct 1600: This is 4 hours after the 1200 vital signs, following the every 4-hour schedule.
E. Correct 1400: This is 4 hours after the 1000 vital signs, following the every 4-hour schedule.
F. Correct 0900: This is the initial vital sign assessment upon admission to the trauma unit at 0100, and it's also 4 hours after the 0500 vital signs.
G. Correct 0800: This is 4 hours after the 0400 vital signs, following the every 4-hour schedule.
H. Incorrect 0500: This is 3 hours after the initial vital sign assessment at 0100. The scheduled assessments are every 4 hours, so the nexta one would be at 0900.
I. Correct 1100: This is 4 hours after the 0700 vital signs, following the every 4-hour schedule.
J. Correct 1200: This is 4 hours after the 0800 vital signs, following the every 4-hour schedule.
Correct Answer is B
Explanation
Shortness of breath on exertion in a client with a history of chronic obstructive pulmonary disease (COPD) and pneumonia indicates increased respiratory distress and compromised lung function. It suggests that the client is experiencing difficulty breathing even with minimal physical exertion. This finding may indicate worsening respiratory status, increased oxygen demand, and inadequate oxygenation. The nurse should take immediate action to address the shortness of breath, which may involve providing supplemental oxygen, initiating or adjusting bronchodilator medications, and monitoring the client's respiratory status closely. Prompt intervention is crucial to ensure adequate oxygenation and prevent respiratory failure.
While the other assessment findings (bilateral diffuse wheezing, temperature of 100.5 °F, and yellow expectorated sputum) are also important and require attention, the shortness of breath on exertion poses the greatest immediate risk and necessitates immediate intervention to address the client's respiratory distress.
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