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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
A. While frequent mouth care is important, it is not the most immediate concern during an active seizure. The priority is to maintain airway patency and prevent aspiration.
B. Maintaining a semi-Fowler's position may be beneficial, but the client’s level of consciousness and the presence of seizures require more immediate interventions focused on airway management.
C. Ensuring oral suction is available is essential for the client who is unconscious and experiencing seizures, as it allows for rapid intervention to clear secretions and prevent aspiration, which is critical for airway protection.
D. Keeping the room at a comfortable temperature is important for the overall comfort of the client, but it does not directly address the acute management of seizures and airway concerns.
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.