Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a pediatric client receiving radiation therapy to the abdominal area. Which of the following statements by the nurse promotes proper skin integrity for the client?
A. "Do not wash the area with strong soaps and do not rub the area dry, just pat it dry."
"Do not wash the area with strong soaps and do not rub the area dry, just pat it dry." Radiation therapy can cause skin irritation and dryness. Using mild soap, lukewarm water, and gently patting the area dry helps prevent further irritation and promotes skin integrity.
B. "Apply some triple antibiotic ointment to help the dryness and itching."
"Apply some triple antibiotic ointment to help the dryness and itching." Antibiotic ointments are not recommended unless there is an infection. Instead, radiation patients should use gentle, fragrance-free moisturizers as directed by their provider.
C. "You should get an abdominal binder and try to keep the area covered."
"You should get an abdominal binder and try to keep the area covered." Tight or restrictive clothing can further irritate the skin and increase the risk of breakdown in the radiation-exposed area.
D. "You need to keep the area exposed to air and direct sunshine."
"You need to keep the area exposed to air and direct sunshine." Direct sun exposure can worsen radiation burns and should be avoided. The skin in the treated area is more sensitive to UV rays and at a higher risk for damage.
This question is an excerpt from Nurse Dive's nursing test bank - Ati rn paediatrics nursing proctored exam 2023. Take the full exam now
Full Explanation
A. "Do not wash the area with strong soaps and do not rub the area dry, just pat it dry." Radiation therapy can cause skin irritation and dryness. Using mild soap, lukewarm water, and gently patting the area dry helps prevent further irritation and promotes skin integrity.
B. "Apply some triple antibiotic ointment to help the dryness and itching." Antibiotic ointments are not recommended unless there is an infection. Instead, radiation patients should use gentle, fragrance-free moisturizers as directed by their provider.
C. "You should get an abdominal binder and try to keep the area covered." Tight or restrictive clothing can further irritate the skin and increase the risk of breakdown in the radiation-exposed area.
D. "You need to keep the area exposed to air and direct sunshine." Direct sun exposure can worsen radiation burns and should be avoided. The skin in the treated area is more sensitive to UV rays and at a higher risk for damage.
Similar Questions
A nurse is teaching an adolescent how to manage his cystic fibrosis. Which of the following statements by the adolescent indicates an understanding of the teaching?
A. "I will be excused from physical education class."
"I will be excused from physical education class." Exercise is encouraged for children with cystic fibrosis (CF) because it helps clear mucus from the lungs and improves overall lung function.
B. "I will increase my intake of vitamin D."
"I will increase my intake of vitamin D." People with CF have difficulty absorbing fat-soluble vitamins (A, D, E, and K) due to pancreatic insufficiency. Vitamin D supplementation is essential to prevent deficiencies and support bone health.
C. "I will limit my calcium intake to prevent kidney stones."
"I will limit my calcium intake to prevent kidney stones." CF patients are at risk for osteoporosis due to malabsorption of calcium and vitamin D, so they should increase, not limit, their calcium intake.
D. "I will take fewer enzymes when I eat high-fat foods."
"I will take fewer enzymes when I eat high-fat foods." CF patients require pancreatic enzyme replacement therapy (PERT) with every meal and snack to aid digestion. More enzymes, not fewer, are needed for high-fat meals to properly digest and absorb nutrients.
Full Explanation
A. "I will be excused from physical education class." Exercise is encouraged for children with cystic fibrosis (CF) because it helps clear mucus from the lungs and improves overall lung function.
B. "I will increase my intake of vitamin D." People with CF have difficulty absorbing fat-soluble vitamins (A, D, E, and K) due to pancreatic insufficiency. Vitamin D supplementation is essential to prevent deficiencies and support bone health.
C. "I will limit my calcium intake to prevent kidney stones." CF patients are at risk for osteoporosis due to malabsorption of calcium and vitamin D, so they should increase, not limit, their calcium intake.
D. "I will take fewer enzymes when I eat high-fat foods." CF patients require pancreatic enzyme replacement therapy (PERT) with every meal and snack to aid digestion. More enzymes, not fewer, are needed for high-fat meals to properly digest and absorb nutrients.
A nurse is preparing to obtain a urine specimen from a 5-month-old infant using a urine collection bag. Which of the following actions should the nurse take?
A. Attach the bag first to the perineum, then to the skin above the urethra.
"Attach the bag first to the perineum, then to the skin above the urethra." Proper technique involves first securing the collection bag to the perineum to ensure a snug fit, then pressing it firmly to the surrounding skin to prevent leaks.
B. Remove the bag 1 hr after the infant voids.
"Remove the bag 1 hr after the infant voids." The bag should be removed as soon as sufficient urine is collected to avoid contamination or leakage.
C. Place absorbent cotton balls inside the bag.
"Place absorbent cotton balls inside the bag." Absorbent materials would absorb the urine, making it difficult to retrieve an adequate sample for testing.
D. Apply petroleum jelly to the perineum before applying the bag.
"Apply petroleum jelly to the perineum before applying the bag." Petroleum jelly could prevent the bag from adhering properly, leading to leakage or contamination.
Full Explanation
A. "Attach the bag first to the perineum, then to the skin above the urethra." Proper technique involves first securing the collection bag to the perineum to ensure a snug fit, then pressing it firmly to the surrounding skin to prevent leaks.
B. "Remove the bag 1 hr after the infant voids." The bag should be removed as soon as sufficient urine is collected to avoid contamination or leakage.
C. "Place absorbent cotton balls inside the bag." Absorbent materials would absorb the urine, making it difficult to retrieve an adequate sample for testing.
D. "Apply petroleum jelly to the perineum before applying the bag." Petroleum jelly could prevent the bag from adhering properly, leading to leakage or contamination.
A nurse is caring for a preschooler who has a gastrostomy tube. Which of the following actions should the nurse take?
A. Use barrier ointments around the site.
"Use barrier ointments around the site." Barrier ointments (such as zinc oxide or petroleum-based products) help prevent skin irritation and breakdown caused by leakage of gastric contents.
B. Cleanse the tube site with hydrogen peroxide.
"Cleanse the tube site with hydrogen peroxide." Hydrogen peroxide can be too harsh and may delay healing or cause irritation to the skin. Mild soap and water or saline are recommended for cleaning.
C. Maintain tension between the tubing and the site.
"Maintain tension between the tubing and the site." The tube should be secured but not under tension, as excessive pulling can cause discomfort, skin breakdown, or accidental dislodgement.
D. Place a transparent occlusive dressing over the site.
"Place a transparent occlusive dressing over the site." A gauze dressing may be used if there is drainage, but a transparent occlusive dressing can trap moisture, increasing the risk of infection.
Full Explanation
A. "Use barrier ointments around the site." Barrier ointments (such as zinc oxide or petroleum-based products) help prevent skin irritation and breakdown caused by leakage of gastric contents.
B. "Cleanse the tube site with hydrogen peroxide." Hydrogen peroxide can be too harsh and may delay healing or cause irritation to the skin. Mild soap and water or saline are recommended for cleaning.
C. "Maintain tension between the tubing and the site." The tube should be secured but not under tension, as excessive pulling can cause discomfort, skin breakdown, or accidental dislodgement.
D. "Place a transparent occlusive dressing over the site." A gauze dressing may be used if there is drainage, but a transparent occlusive dressing can trap moisture, increasing the risk of infection.