Nokea
The nurse is caring for a client who 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. Avoid washing the skin inside the radiation portal site.
- C. Remove the ink marks of the portal after each radiation treatment.
- D. Apply moisture lotions daily to the radiation portal site.
Correct Answer: A
Rationale: Protecting the radiation portal site from sunlight exposure prevents further damage to the sensitive irradiated skin.
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While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?
- A. White blood cell (WBC) count.
- B. Hematocrit.
- C. Blood pH level.
- D. Platelet count.
Correct Answer: A
Rationale: Reviewing the white blood cell count is important because purulent drainage suggests infection, and an elevated WBC count may indicate an inflammatory response to infection.
The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?
- A. Using salt, herbs, and spices will improve the flavor of foods.
- B. Restrict alcoholic beverages to no more than 1-2 per week.
- C. Eat a protein snack 30 minutes before any exercise workout.
- D. Get an influenza vaccine every year as soon as available.
Correct Answer: D
Rationale: Getting an influenza vaccine every year is a crucial aspect of diabetes self-management, as people with diabetes are at increased risk of complications from influenza.
A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?
- A. Obtain a keyboard designed to limit wrist flexion.
- B. Use a space heater to keep the workspace warm.
- C. Take a multivitamin that contains vitamin D daily.
- D. Keep both hands elevated during work breaks.
Correct Answer: B
Rationale: Maintaining warmth is crucial for Raynaud's syndrome to prevent vasospastic attacks triggered by cold exposure, ensuring proper blood flow.
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?
- A. Assess the pin sites for signs of infection.
- B. Administer pain medication at designated intervals around the clock.
- C. Assess the pulses proximal to the fracture site.
- D. Remove traction every shift and provide skin care.
Correct Answer: A
Rationale: Assessing pin sites for signs of infection is essential to detect early signs of complications in skeletal traction.
A client who has small cell carcinoma of the lung is admitted with symptoms of syndrome of inappropriate antidiuretic hormone (SIADH). As the client's serum sodium level increases from 120 mEq/L to 125 mEq/L, which intervention should the nurse implement?
- A. Assess for increasing fluid volume overload.
- B. Withhold next scheduled dose of treatment.
- C. Increase neurologic checks to every 2 hours.
- D. Maintain the prescribed fluid restriction.
Correct Answer: D
Rationale: Maintaining the prescribed fluid restriction is essential to prevent further dilutional hyponatremia and to help normalize the serum sodium level gradually.