Hesi Case Studies–medical/surgical-cervical Cancer (mrs. Judy Sailor) Test Questions – Flashcards
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5. Which explanation about HPV quadrivalent vaccine is best to give to Mrs. Sailor?
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HPV quadrivalent vaccine does not treat cervical cancer
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6. In response to the client's statement, which concern is most important for the RN to explore in greater depth?
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Sexual limitations as a result of the surgery
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7. Based on the RN's assessment, what is the priority nursing diagnosis for this clients?
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Ineffective sexuality pattern related to physiological limitations
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8. Which intervention should the RN include in Mrs. Sailor's plan of care?
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Provide accurate and timely teaching regarding the client's sexual concerns
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9. After Mrs. Sailor expresses concern about nausea and vomiting while taking chemotherapy, what information should the RN provide?
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Nausea and vomiting are anticipated, so medications will be given to prevent them
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10. Ondansetron is ordered 8mg IVPB prior to administration of cisplatin. Ondansetron is available in 4mg/2mL. How may mL should the RN administer?
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4
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11. Which laboratory result is most important for the RN to report to the HCP?
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White blood cell (WBC) count 1,700/mm^3
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12. It is important for the RN to include which priority client education based on the prescribed therapy?
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Report a fever greater than 100.4F
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13. What additional information should the RN obtain about the side effects of cisplatin? (Select all)
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-Presence of cough or productive sputum -Frequency of urination -Reports of malaise and chills
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14. Which prescription should the RN implement first?
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Collect specimens for cultures
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15. To which room should the RN admit Mrs. Sailor?
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Private room close to the nurse's station
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16. Mrs. Sailor's son and 4-year-old grandchild arrive for a visit. What action should the nurse implement?
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Allow the grandchild to visit from the doorway
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17. The RN is teaching the client how to prevent further complications of neutropenia. Which instruction is most important?
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Wash hands frequently
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18. While the RN is reviewing instructions with the client, Mrs. Sailor's husband arrives with a box of chocolates and a beautiful boquet of long-stem roses. What action should the RN take?
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Advise the husband that roses are a source of infection
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19. At change of shift report, the RN is assigned Mrs. Sailor and three additional clients for the day shift. Which client should the RN assess first?
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A 58-year-old receiving fluorouracil and methotrexate for colon cancer who reports having three diarrhea stools
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20. To evaluate the effectiveness of diphenhydramine, the RN should assess for which findings?
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Absence of itching, urticaria, and flushing
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21. Which action is most important for the RN to implement to avoid blood-related transfusion reactions when preparing to administer Mrs. Sailor's unit of PRBC?
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Match the label on the blood with the client's identification band
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22. Upon further inspection, the RN observes a small amount of swelling at the site and sluggish fluid infusion of normal saline. What action should the RN implement?
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Discontinue the infusion and restart at another site
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23. The client is scheduled to receive potassium chloride 40mEq/L in 400mL over 4 hours. The RN should set the infusion pump to deliver how many mL per hour?
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100
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24. One hour after the initiation of the IV infusion of potassium chloride, the RN reassess Mrs. Sailor. Which nursing assessment has the highest priority?
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Complaining of palpitations and a heavy feeling in the chest
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25. Which assessment data indicates to the Rn that the desired outcome of the filgrastim has been achieved?
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WBC count 3,500/mm^3
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26. What information about the expected side effects of filgrastim should the RN include in the discharge teaching plan for Mrs. Sailor?
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Mild to moderate bone pain
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27. According to The Joint Commission's National Patient Safety Goals (NPSG), what is the priority action for the RN?
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Complete a list of medications
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