An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?

Correct Answer: C

Rationale: The correct position for administering a soap suds enema is the Sims' position, not the left lateral position. The Sims' position allows the enema solution to follow the anatomical course of the intestines and provides the best overall results. By repositioning the client in the Sims' position, the weight is distributed to the anterior ilium, facilitating the enema administration process.

Correct Answer: C

Rationale: In the context of a client receiving external radiation therapy for lung cancer, the most important intervention for the nurse to include in the plan of care is option C: Instruct the client to avoid using deodorant on the skin near the radiation site. This is crucial because deodorants often contain metals that can react with the radiation, leading to skin irritation, burns, or other adverse effects. Option A: Encouraging sunscreen use when outdoors is important for skin protection, but it is not directly relevant to the radiation therapy site and the specific concerns associated with it. Option B: Applying a heating pad to the radiation site can increase blood flow and potentially exacerbate skin reactions, making it an inappropriate intervention. Option D: Advising the client to increase intake of green leafy vegetables is generally beneficial for health but does not directly address the specific care needs related to radiation therapy. In an educational context, understanding the rationale behind each option helps students grasp the importance of tailored care plans in radiation therapy. By selecting the correct answer, students learn the critical nature of preventing potential interactions that could compromise the effectiveness of treatment and patient safety. This question emphasizes the significance of precise interventions in nursing care to optimize patient outcomes during cancer treatment.

Correct Answer: C

Rationale: In right-sided heart failure, the heart's inability to effectively pump blood to the lungs leads to fluid backup in the systemic circulation, resulting in peripheral edema (swelling in lower extremities). While jugular vein distention (A) and hepatomegaly (D) can also occur in right-sided heart failure, peripheral edema is a hallmark sign due to fluid retention. Crackles in the lungs (B) are more commonly associated with left-sided heart failure, where fluid accumulates in the lungs.

Correct Answer: A

Rationale: The correct answer is A: 'Avoid foods high in iodine.' Clients with hyperthyroidism should avoid foods high in iodine to prevent exacerbation of their condition. Iodine is an essential component in thyroid hormone production, and excessive iodine intake can worsen hyperthyroidism symptoms. Taking medication with meals (B) can interfere with the absorption of certain thyroid medications. Monitoring weight daily (C) is more relevant for conditions that may lead to weight changes like hypothyroidism. Decreasing fluid intake (D) is not a standard recommendation for hyperthyroidism unless specifically indicated by the healthcare provider.

Correct Answer: C

Rationale: Keeping the drainage system below the level of the chest (C) is crucial to ensure proper drainage and prevent backflow of air or fluid into the chest cavity. This position helps maintain the integrity of the closed drainage system. Ensuring the chest tube remains unclamped at all times (A) allows for continuous drainage. Emptying the chest tube (B) should be done as needed, not routinely every 2 hours. Assessing for subcutaneous emphysema (D) is important but not the most critical action in this scenario.