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 ["A","C","E"]

Explanation

The correct answer/s is Choice/s A, C, and E.

Choice A rationale: Obtaining the client’s tympanic temperature measurement is a crucial step. The client’s confusion and disorientation could be symptoms of an infection, such as a urinary tract infection or pneumonia. Infections in older adults can often present with atypical symptoms, including changes in mental status. Therefore, checking the client’s temperature can help identify if the client has a fever, which is a common sign of an infection.

Choice B rationale: While it’s always important to be aware of a client’s allergies, especially when administering medications, it doesn’t directly address the immediate concern of the client’s altered mental status. Therefore, it’s not the most appropriate action to take in response to the situation described.

Choice C rationale: Asking if the client is experiencing any pain with urination is relevant because urinary tract infections (UTIs) are common in older adults and can cause confusion and other changes in mental status. Pain during urination is a common symptom of a UTI.

Choice D rationale: Encouraging the intake of high protein foods is generally a good recommendation for older adults to maintain their strength and energy levels. However, it’s not directly related to the client’s current symptoms of confusion and disorientation.

Choice E rationale: Determining if the client has recently experienced a fall is important. Falls in older adults can lead to injuries, such as a head injury, which can cause confusion and other changes in mental status. Additionally, some medications used to treat pain after a fall can also contribute to confusion.

Correct Answer is ["9"]

Explanation

Here are the steps you can follow to calculate the infusion pump flow rate:

Step 1: Calculate the prescribed dose in mcg/min

Dose per weight: 2 mcg/kg/min * 60 kg = 120 mcg/min

Step 2: Convert the concentration in the IV bag to mcg/mL

Convert mg to mcg: 200 mg * 1000 mcg/mg = 200,000 mcg
Concentration: 200,000 mcg / 250 mL = 800 mcg/mL

Step 3: Calculate the flow rate in mL/min

Flow rate: 120 mcg/min / 800 mcg/mL = 0.15 mL/min

Step 4: Convert the flow rate to mL/hour

Hour conversion: 0.15 mL/min * 60 min/hour = 9 mL/hour

Therefore, the nurse should program the infusion pump to deliver 9 mL/hour.

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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

An older client is taken to the clinic by the spouse, who appears extremely worried. The spouse reports to the nurse that the client started to not make any sense and asked to visit a brother who has been dead for many years. Which action(s) should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

The healthcare provider prescribes dopamine 2 mcg/kg/min intravenously (IV) for client who weighs 60 kg. The IV bag contains dopamine 200 mg in dextrose 5% in water (DW) 250 mL. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numerical value only.)

Correct Answer is ["9"]

Explanation

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