Case Study 11 - Multiple Pts with Cancer

1

Which assessment finding is most critical? 1. Mr. U has tracheal deviation after pulm resection 2. Mr. B with bladder cancer has decreased output 3. Mr. N with NHL is having dysrhythmias 4. Ms. C has severe abdominal pain after bowel resection

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During the midmorning, the following events occur at the same time. Prioritize the events in order in which they should be addressed. 1. Mr. B who had bladder cancer reports dysuria 2. Mr. U's (pulm resection) chest drainage system has tipped over 3. Mr. N, with NHL, has a fever of 101 F 4. Mr. L's (partial laryngectomy) trach tube needs to be suctioned 5. Ms. C, who had bowel resection, has a swollen, tender, red calf

3

Following the BCG tx, you delegate disposal of Mr. B's Foley bag and fluid contents to the UAP. What instruction should you give? 1. no special handling of the bag or its contents is required 2. wear a lead apron when you empty the drainage container 3. discard the fluid in the toilet and disinfect the toilet with bleach for 6 h 4. wear sterile gloves when you are handling the bag and its contents

1. UAP 2. RN 3. RN 4. WOCN 5. WOCN

In helping a client such as Ms. C who had a colostomy with bowel resection, which team member (RN, UAP, WOCN), should be assigned to perform each action? 1. assist with peri care 2. administer stool softeners and assess effectiveness 3. monitor wounds for drainage and infx 4. provide initial info about ostomy care and mngmt 5. advise about prevention of skin breakdown around stoma site

4

In the early postop period, what is the priority top nursing dx for Mr. L, who has a trach and partial laryngectomy? 1. risk for infx r/t chemo and surgery 2. imbalanced nutrition: less than body req r/t presurgical dysphagia and malignancy 3. impaired verbal communication r/t trach tube 4. risk for aspiration r/t secretions and removal of epiglottis

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Mr. B will receive intravesical chemo consisting of bacille Calmette-Guerin (BCG) instillation for his bladder cancer. Place the following steps r/t this therapy in the correct order. 1. clamp the tube distal to the injection port of the cath 2. insert a Foley 3. instill BCG fluid via the catheter 4. change the client's position from side to side q15mins for 2 hours 5. direct the client to drink 2 glasses of water to flush the bladder 6. unclamp the catheter at the end of 2 hours

3

Ms. C repeatedly calls for help during the shift with various small requests. She is talkative and pleasant, and she does everything she can to get you to "stay and chat." What is the best response? 1. i really do like talking to you, but i do have other clients 2. you'll be okay for right now and i will come back and check on you later 3. i have 10 minutes right now. later this afternoon, i'll have time to talk 4. let me call one of the hospital volunteers to come and sit with you

4

Ms. C repeatedly refuses to perform a return demonstration of any aspect of colostomy care. Despite steady improvement and independent resumption of other ADLs, she protests "I'm too weak. You'll have to do it for me." What is the priority dx for her? 1. activity intolerance r/t disease process 2. risk for impaired skin integrity r/ ostomy 3. deficient knowledge r/t procedure 4. defensive coping r/t change in health and ADLs

4

Ms. G continues to be anxious and tearful and she tells you that she has changed her mind about the surgery, "I'm going to go home. I just can't deal with everything that is going on right now. I need some time to think about things." What is your best response? 1. it's okay to change your mind. you have the right to make your own decisions. 2. please reconsider. this surgery is very important and your health is the priority 3. would you like me to call your HCP so that you can discuss your concerns? 4. i see you are very concerned. what things are you dealing with and thinking about?

3

The HCP should be notified if a normal voiding pattern (pain free, symptom free) fails to resume within which time period after removal of Mr. B's cath (after BCG tx)? 1. 6 h 2. 12 h 3. 3 days 4. 1 week

4

The nursing staff are making suggestions about how to help Ms. C overcome her reluctance to perform colostomy care. Which suggestion will you try first? 1. verbally reexplain the procedure and give written material 2. have a family member come in and do it for her 3. continue to do it for her until she is ready 4. ask her to hold the clamp while the bag is being emptied

3

The nursing student tearfully reports to you, "I took some flowers into Mr. N's room to cheer him up and he told me that he didn't think he was supposed to have flowers. I took them out of the room right away and then I realized I had made a mistake." What should you do first? 1. direct the student to read the isolation precautions before entering the room 2. call the nursing instructor and report the student for making an error 3. acknowledge and praise the student for taking responsibility for the mistake 4. write an incident report and have the student and instructor sign it

2

The nursing student tells you that Ms. C has just asked her to stay after the shift ends so that she can meet her granddaughter. What should you say to the student? 1. what do you think your instructor would tell you to do 2. what do you think about her request 3. it sounds like you really made a connection with Ms C 4. tell Ms. C that you have to go, but you will see her tomorrow

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There are 2 hours left before the shift ends. The new UAP tells you that she has to leave now b/c she has a family emergency. What should you do? (select all) 1. ask her what tasks and duties are pending for the next 2 h 2. call a UAP who is scheduled for the next shift to come early 3. remind the UAP that shift change is a busy time 4. allow her to leave but remind her she is still on probation as a new staff member 5. call another unit and see if there is a UAP who could float to your unit 6. explain to her that her priority is to fulfill her work responsibilities 7. ask her to explain the nature of the family emergency so that you can make a decision 8. check with the other staff members to see if they will be able to cover her duties

1

Which assessment finding for Mr. L (50 yo transferred 6 days ago following trach and partial laryngectomy) is of greatest concern? 1. pulsation of trach tube in synchrony with heartbeat 2. increased secretions in and around trach 3. increased coughing with difficulty in expectorating secretions 4. presence of food particles in trach secretions

3

You are reviewing new orders for Mr. N (neutropenic precautions). Which order would you question? 1. administer filgrastim (Neupogeni) 5 mcg/kg SQ every day 2. catheterize to obtain UA specimen 3. flush IV saline lock every shift 4. monitor VS every hours

3

You are teaching the nursing student about emergency resp equipment that should be available for Mr. L. Which piece of equipment is the most important to show to the student? 1. adult-sized ETT 2. laryngeal scope with blades of several sizes 3. bag-valve mask with extension tubing 4. trach insertion tray

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You are the leader of a team caring for clients on a med-surg oncology unit. Your clients are as follows: Mr. N (68 yo, went to see HCP with fever, wt loss, painless axillary nodes; after lymph node biopsy, NHL was dx; receiving chemo and is on neutropenic precautions; currently afebrile, in good spirits, feels reasonably well) Mr. L (50 yo, transferred 6 days ago from surgical ICU following trach and partial laryngectomy; has soft, small-bore NG tube and trach tube, currently receiving chemo; received radiation therapy before surgery) Mr. B (59 yo, went to HCP with painless hematuria, bladder cancer dx; admitted for intravesical chemo, received procedure-related teaching before admission; he is alert, conversant, independently performs ADLs) Ms. C (70 yo, went to HCP for rectal bleeding and change in bowel habits; had bowel resection and colostomy 5 days ago; progressing well, but needs and likes companionship at bedside) Ms. G (65 yo admitted for right breast lumpectomy, scheduled for later in day, will be followed by radiation, appears nervous and tearful, frequently asking questions) Mr. U (62 yo, hx of cough, hemoptysis, fatigue, dyspnea, dx is non-small cell lung cancer after bronchoscopy and sputum cytologic analysis; underwent pulmonary resection 5 days ago and has chest tube drainage system) The first-semester nursing student tells you that her clinical assignment for the day is to take VS and obtain a client hx that will take about 1 or 2 hours to complete. Which clients would you recommend she approach to fulfill her assignment? (select all) 1. Mr. N 2. Mr. L 3. Mr. B 4. Ms. C 5. Ms. G 6. Mr. U

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You are the leader of a team caring for clients on a med-surg oncology unit. Your clients are as follows: Mr. N (68 yo, went to see HCP with fever, wt loss, painless axillary nodes; after lymph node biopsy, NHL was dx; receiving chemo and is on neutropenic precautions; currently afebrile, in good spirits, feels reasonably well) Mr. L (50 yo, transferred 6 days ago from surgical ICU following trach and partial laryngectomy; has soft, small-bore NG tube and trach tube, currently receiving chemo; received radiation therapy before surgery) Mr. B (59 yo, went to HCP with painless hematuria, bladder cancer dx; admitted for intravesical chemo, received procedure-related teaching before admission; he is alert, conversant, independently performs ADLs) Ms. C (70 yo, went to HCP for rectal bleeding and change in bowel habits; had bowel resection and colostomy 5 days ago; progressing well, but needs and likes companionship at bedside) Ms. G (65 yo admitted for right breast lumpectomy, scheduled for later in day, will be followed by radiation, appears nervous and tearful, frequently asking questions) Mr. U (62 yo, hx of cough, hemoptysis, fatigue, dyspnea, dx is non-small cell lung cancer after bronchoscopy and sputum cytologic analysis; underwent pulmonary resection 5 days ago and has chest tube drainage system) You make very brief rounds to see each client before receiving shift report to ensure client safety and to help determine acuity & assignments. Which actions will these brief assessments entail? (select all) 1. ask, "How are you feeling" 2. noting mental status (alert and oriented?) 3. measure VS and look at I/O 4. palpate chest and abdominal areas for pain 5. note presence and complexity of equipment 6. observe ease of resp effort

1

You are working through the preop checklist and Ms. G, who has a breast lump, begins to cry. "What do you think about this breast surgery? My friend's arm got really swollen after she had surgery. Can't I just take medication?" What is the priority dx for her? 1. anxiety r/t uncertainty about future outcomes 2. disturbed body image r/t imminent loss of body part 3. deficient knowledge r/ tx plan 4. noncompliance r/t surgical procedure

1

You determine that Mr. U has developed a tension pneumo following surgery for pulm resection 5 days ago. He is currently receiving high-flow O2 via nonrebreather mask but continues to experience resp distress. What is the priority action? 1. remove occlusive dressing around chest wound 2. perform needle thoracotomy with a 14-16 gauge catheter needle 3. initiate CPR 4. call for the crash cart and intubation equipment

2

You must assign a UAP to help care for Mr. N with non-Hodgkin lymphoma. For this neutropenic client, which factor is most important in making this assignment? 1. UAP is in 1st trimester 2. UAP has had cold symptoms for 3 days 3. UAP has no experience with neutropenic precautions 4. UAP has a generalized fear of isolation pts