HESI Case Studies–Medical/Surgical-Cervical Cancer (Mrs. Judy Sailor)

1. What information is most important for the RN to obtain to determine Mrs. Sailor’s risk for cervical cancer? (Select all)
-History of sexual partners
-Age with first pregnancy
2. When developing a plan of care to reduce the risks for cervical cancer, the RN recognizes that primary prevention should include which intervention?
Provide community education
3. After speaking with the RN, Mrs. Sailor understands that the endocervical biopsy will be done by cervical conization to allow for microscopic examination of the cervical tissue. She is scheduled for cervical conization in 2 day. How should the RN respond to the client?
Ask the client about her understanding of the abnormal pap smear result
4. When Mrs. Sailor asks the RN where the bioopsy will take place, how should the RN respond?
The HCP’s office
5. Which explanation about HPV quadrivalent vaccine is best to give to Mrs. Sailor?
HPV quadrivalent vaccine does not treat cervical cancer
6. In response to the client’s statement, which concern is most important for the RN to explore in greater depth?
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?
Ineffective sexuality pattern related to physiological limitations
8. Which intervention should the RN include in Mrs. Sailor’s plan of care?
Provide accurate and timely teaching regarding the client’s sexual concerns
9. After Mrs. Sailor expresses concern about nausea and vomiting while taking chemotherapy, what information should the RN provide?
Nausea and vomiting are anticipated, so medications will be given to prevent them
10. Ondansetron is ordered 8mg IVPB prior to administration of cisplatin. Ondansetron is available in 4mg/2mL. How may mL should the RN administer?
4
11. Which laboratory result is most important for the RN to report to the HCP?
White blood cell (WBC) count 1,700/mm^3
12. It is important for the RN to include which priority client education based on the prescribed therapy?
Report a fever greater than 100.4F
13. What additional information should the RN obtain about the side effects of cisplatin? (Select all)
-Presence of cough or productive sputum
-Frequency of urination
-Reports of malaise and chills
14. Which prescription should the RN implement first?
Collect specimens for cultures
15. To which room should the RN admit Mrs. Sailor?
Private room close to the nurse’s station
16. Mrs. Sailor’s son and 4-year-old grandchild arrive for a visit. What action should the nurse implement?
Allow the grandchild to visit from the doorway
17. The RN is teaching the client how to prevent further complications of neutropenia. Which instruction is most important?
Wash hands frequently
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?
Advise the husband that roses are a source of infection
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?
A 58-year-old receiving fluorouracil and methotrexate for colon cancer who reports having three diarrhea stools
20. To evaluate the effectiveness of diphenhydramine, the RN should assess for which findings?
Absence of itching, urticaria, and flushing
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?
Match the label on the blood with the client’s identification band
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?
Discontinue the infusion and restart at another site
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?
100
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?
Complaining of palpitations and a heavy feeling in the chest
25. Which assessment data indicates to the Rn that the desired outcome of the filgrastim has been achieved?
WBC count 3,500/mm^3
26. What information about the expected side effects of filgrastim should the RN include in the discharge teaching plan for Mrs. Sailor?
Mild to moderate bone pain
27. According to The Joint Commission’s National Patient Safety Goals (NPSG), what is the priority action for the RN?
Complete a list of medications