A client receiving external radiation to the left thorax to treat lung cancer has a nursing diagnosis of Risk for impaired skin integrity. Which intervention should be part of this client's plan of care?

Correct Answer: A

Rationale: The correct intervention that should be part of the plan of care for a client at risk for impaired skin integrity due to external radiation is avoiding using a soap on the irradiated areas. Soap can be drying to the skin and may exacerbate skin reactions caused by radiation therapy. It is important to keep the skin in the radiation field clean, but avoiding soap will help prevent further irritation and damage to the skin. Instead, a gentle cleanser recommended by the healthcare provider should be used to clean the irradiated areas. Additionally, maintaining good hydration and moisturizing the skin as recommended by the healthcare team can also help minimize skin reactions.

Correct Answer: B

Rationale: The presence of flatus (gas) is a positive sign that the patient's gastrointestinal tract is resuming normal function after a bowel resection surgery. Flatus production indicates that peristalsis and normal bowel motility are returning, allowing gas to move through the intestine. This is an important milestone in the postoperative recovery process, as it suggests the return of normal bowel function. The other options provided are not indicative of the return of normal gastrointestinal function.

Correct Answer: C

Rationale: The presence of fluid in both lung bases, as indicated by the chest x-ray examination, suggests the possibility of pulmonary congestion or fluid accumulation in the lungs. Bilateral crackles, also known as rales, are a common clinical finding associated with pulmonary edema. Crackles are discontinuous, brief, popping sounds heard on auscultation of the lungs. These adventitious breath sounds occur when air passes through fluid in the small airways or alveoli. Therefore, the presence of bilateral crackles during the nurse's assessment would most reflect the x-ray examination findings of fluid in both lung bases. Fatigue, peripheral edema, and jugular vein distention may also be present in conditions involving fluid overload, such as heart failure, but bilateral crackles specifically point to the presence of fluid in the lungs.

Correct Answer: C

Rationale: When caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion, it is important to promote optimal blood flow to the tissues. Positioning the lower extremities below the level of the heart helps to facilitate venous return and improve circulation to the extremities. This position helps reduce the workload on the heart and promotes better perfusion to the tissues, ultimately aiding in the prevention of complications related to ineffective tissue perfusion. The other options (A. Restrict fluid intake, B. Ensure that the client avoids prolonged sitting, D. Instruct the client to avoid leg exercises) are not directly related to improving tissue perfusion and may not be appropriate interventions in this situation.

Correct Answer: C

Rationale: The nurse instructs the client to avoid Valsalva maneuvers because the client may suffer from a myocardial infarction. The Valsalva maneuver involves forcefully trying to exhale against a closed airway, which can increase intra-thoracic pressure and subsequently increase blood pressure. This can lead to an increased workload on the heart, potentially causing myocardial ischemia or infarction in individuals with underlying heart conditions. Therefore, it is important to avoid Valsalva maneuvers, especially in clients at risk for cardiovascular issues.