The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instructions regarding skin care of the portal site should the nurse provide?
Remove the ink marks of the portal after each radiation treatment.
Protect the skin of the radiation portal site from sunlight exposure.
Apply moisture lotions daily to the radiation portal site.
Avoid washing the skin inside the radiation portal site.
The Correct Answer is B
A. Removing ink marks can lead to difficulty in accurately targeting the radiation area, so the marks should be left in place until the treatment course is complete.
B. Protecting the skin from sunlight exposure is crucial, as the irradiated skin is more sensitive and at increased risk for sunburn. This recommendation helps to prevent further irritation and damage to the skin during and after treatment.
C. While moisturizing lotions can be beneficial for maintaining skin integrity, they should be used cautiously and only if prescribed by the healthcare provider, as some products may cause irritation.
D. The skin inside the radiation portal site should be washed gently with mild soap and water to keep it clean; avoiding washing is not advisable as it can lead to skin breakdown.
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Correct Answer is B
Explanation
A. Bronze pigmentation is often associated with venous insufficiency rather than arterial compromise.
B. Compromised peripheral arterial circulation can lead to decreased blood flow, resulting in uneven or diminished hair distribution on the lower extremities due to lack of nourishment to hair follicles.
C. Lower leg edema is more commonly associated with venous insufficiency rather than arterial insufficiency.
D. A bounding peripheral pulse indicates increased arterial pressure or volume, which is not consistent with compromised arterial circulation, where pulses are typically weak or absent.
Correct Answer is C
Explanation
A. Oxycodone is an opioid analgesic used for moderate to severe pain management but is not typically the first-line medication in acute coronary syndrome scenarios.
B. Fentanyl is a potent opioid that may be used for severe pain; however, morphine is more commonly used in emergency situations for chest pain related to potential myocardial infarction.
C. Morphine is commonly used in emergency departments for the management of acute chest pain, particularly when associated with myocardial ischemia. It helps reduce pain and anxiety, lowers myocardial oxygen demand, and has vasodilatory effects that can alleviate the burden on the heart.
D. Hydromorphone is another opioid analgesic but is not usually the preferred choice for chest pain in the acute setting compared to morphine.