Nokea
The client is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?
- A. Protect the skin of the radiation portal site from sunlight exposure
- B. Apply moisturizing lotions daily to the radiation portal site
- C. Avoid washing the skin inside the radiation portal site
- D. Remove the ink marks of the portal after each radiation treatment
Correct Answer: A
Rationale: Protecting the skin from sunlight exposure is crucial to prevent radiation burns and additional skin damage at the treatment site. Sun exposure can exacerbate skin reactions caused by radiation therapy. Applying moisturizing lotions daily may introduce foreign substances or irritants to the treated area, leading to potential complications. Washing the skin inside the radiation portal site is important for maintaining cleanliness and preventing infections. Removing the ink marks after each treatment is unnecessary and may cause unnecessary skin irritation and trauma.
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A client with chronic renal failure is being treated with sodium polystyrene sulfonate (Kayexalate). The nurse should monitor the client for which of the following?
- A. Hyponatremia.
- B. Hypokalemia.
- C. Hyperkalemia.
- D. Hypocalcemia.
Correct Answer: C
Rationale: The correct answer is C: Hyperkalemia. Sodium polystyrene sulfonate (Kayexalate) is used to treat high potassium levels (hyperkalemia) by exchanging sodium ions for potassium ions in the large intestine, which is then eliminated through the feces. Therefore, the nurse should monitor the client for changes in potassium levels to ensure the effectiveness of the treatment. Choices A, B, and D are incorrect because sodium polystyrene sulfonate (Kayexalate) is not associated with causing hyponatremia, hypokalemia, or hypocalcemia.
The nurse is caring for a client who is scheduled for hemodialysis. Which of the following laboratory values should the nurse monitor closely before, during, and after the procedure?
- A. Hemoglobin level.
- B. Blood urea nitrogen (BUN) level.
- C. Creatinine level.
- D. Serum potassium level.
Correct Answer: D
Rationale: The correct answer is D: Serum potassium level. Before, during, and after hemodialysis, monitoring the serum potassium level is crucial to prevent hyperkalemia, a potentially life-threatening complication. Hemodialysis is done to remove waste products and excess electrolytes like potassium from the blood. Monitoring other laboratory values like hemoglobin, BUN, and creatinine is important in assessing kidney function and anemia, but serum potassium level requires close monitoring during hemodialysis due to the risk of rapid shifts that can lead to cardiac arrhythmias.
In a patient with pneumonia, what is the primary goal of treatment?
- A. Reducing inflammation.
- B. Eliminating the infection.
- C. Reducing pain.
- D. Preventing complications.
Correct Answer: B
Rationale: The primary goal of treating pneumonia is to eliminate the infection. Antibiotics are commonly used to target the specific pathogen causing pneumonia. While reducing inflammation and preventing complications are important aspects of treatment, the key focus initially is on eradicating the infectious agent to improve the patient's condition and prevent further spread of the infection.
The nurse is monitoring a client with chronic renal failure who is receiving hemodialysis. The nurse should report which of the following findings immediately?
- A. Clear dialysate outflow.
- B. Weight gain of 2 lbs (0.9 kg) since the last treatment.
- C. Blood pressure of 130/80 mm Hg.
- D. Pulse rate of 72 bpm.
Correct Answer: B
Rationale: The correct answer is B. Weight gain of 2 lbs (0.9 kg) since the last treatment is concerning in a client undergoing hemodialysis with chronic renal failure as it may indicate fluid overload. This finding requires immediate reporting and intervention to prevent complications such as fluid retention, pulmonary edema, or exacerbation of heart failure. Choices A, C, and D are not findings that require immediate attention in this context. Clear dialysate outflow is a normal finding during hemodialysis, a blood pressure of 130/80 mm Hg is within a normal range for many clients, and a pulse rate of 72 bpm is also within the expected range for most individuals.
After a client with peripheral vascular disease undergoes a right femoral-popliteal bypass graft, their blood pressure drops from 124/80 to 94/62. What should the nurse assess first?
- A. IV fluid infusion.
- B. Pedal pulses.
- C. Nasal cannula oxygen flow rate.
- D. Capillary refill time.
Correct Answer: B
Rationale: Assessing pedal pulses is crucial in this situation as it helps determine the adequacy of perfusion to the lower extremity following a bypass graft. A decrease in blood pressure postoperatively could indicate decreased perfusion, making the assessment of pedal pulses a priority to ensure proper circulation. Checking IV fluid infusion, nasal cannula oxygen flow rate, or capillary refill time are not the immediate priorities in this scenario and would not provide direct information about perfusion to the affected extremity.