The RN is the leader of a team caring for patients on a medical-surgical
oncology unit. In addition to the leader, the team includes an experienced chemotherapy-certified RN, a new assistive personnel (AP), and a first-semester nursing student. The morning hand-off report includes the following information: (Note to student: This case study includes six patients; take notes as though you were listening to the morning report and refer to your notes as you work through the case study.)
Mr. N, a 68-year-old man, went to see his health care provider (HCP) with fever, weight loss, and painless axillary nodes. After a lymph node biopsy, non-Hodgkin lymphoma was diagnosed. He is receiving chemotherapy and is on neutropenic precautions. He is currently afebrile, in good spirits, and feels reasonably well.
Mr. L, a 50-year-old man, was transferred 6 days ago from the surgical intensive care unit (ICU) after a tracheostomy and partial laryngectomy. He has a soft, small-bore nasogastric (NG) tube and a tracheostomy tube and is currently receiving chemotherapy. He received radiation therapy before surgery.
Mr. B, a 59-year-old man, went to his HCP with painless hematuria, and bladder cancer was subsequently diagnosed. He was admitted for intravesical chemotherapy. He received procedure-related teaching before admission. He is alert and conversant, and he independently performs activities of daily living (ADLs).
Ms. C, a 70-year-old woman, went to her HCP because of rectal bleeding and a change in bowel habits. She underwent a bowel resection and colostomy 5 days ago. She is progressing well but needs and likes companionship at the bedside.
Ms. G, a 65-year-old woman, was admitted for a right breast lumpectomy; it is scheduled for later in the day. Radiation therapy is planned as part of the follow-up treatment. She appears nervous and tearful and is frequently asking questions.
Mr. U, a 62-year-old man, has a history of cough, hemoptysis, fatigue, and dyspnea. After bronchoscopy and sputum cytologic analysis, non-small cell lung cancer was diagnosed. He underwent pulmonary resection 5 days ago and has a chest tube drainage system. He is having significant and continuous pain. A patient controlled agalgesia (PCA) pump is being considered, but Mr. U expresses reluctance to use it.
Which assessment finding for Mr. L (tracheostomy and partial laryngectomy) would be of greatest concern?
A. Pulsation of the tracheostomy tube in synchrony with the heartbeat .
B. Increased secretions in and around the tracheostomy.
C. Increased coughing, with difficulty in expectorating secretions .
D. Presence of food particles in tracheal secretions .
The nurse sees that Mr. B (bladder cancer) has received docusate for the past 2 days. Which question is the nurse most likely to ask to evaluate the effectiveness of the docusate?
A. "Has the medication helped to relieve the nausea?"
B. "Are you experiencing any burning with urination?"
C. "Were you able to sleep soundly the last couple of nights?"
D. "Did you have a bowel movement today or yesterday?"
Which two patients are the most critical and likely to require frequent assessment and skilled care through-out the shift? Select two.
1. Mr. U (pulmonary resection)
2. Ms. G (breast lumpectomy)
3. Mr. N (non-Hodgkin lymphoma)
4. Mr. B (bladder cancer)
5. Mr. L (tracheostomy and partial laryngectomy)
6. Ms. C (bowel resection and colostomy)
The team leader is reviewing the pain management plan for Mr. U. He is having significant pain related to the cancer and the pulmonary resection. Which option would be the best for Mr. U?
A. Mr. U has a high risk for respiratory distress, so opioids are not prescribed.
B. Mr. U should be offered the non-opioid medication first to see it if works.
C. Mr. U should receive around-the-clock fixed doses of opioid analgesics.
D. Mr. U is instructed to ask for pain medication whenever he needs it.
Mr. N (non-Hodgkin lymphoma) shyly asks, "Do doctors have a special way that they wash their hands? Everybody washes their hands and then rewashes their hands before they touch me or any of my personal items. Everybody—except that one doctor." What is the team leader's priority action?
A. Contact the infection control person because the HCP probably needs a review of infection control procedures.
B. Reassure the patient that the HCP probably washed his hands just before entering the room.
C. Approach the HCP and explain what the patient noticed and the patient's concerns about the hand washing.
D. Tell the patient that the staff 's actions to protect against infection are based on the latest laboratory results.
Mr. L (tracheostomy and partial laryngectomy) needs to receive a dose of IV chemotherapy during the shift. What is the most important action to take to prevent extravasation?
A. Call the pharmacy to find out if the prescribed medication has vesicant properties.
B. Hold the medication until an implanted port or central line is established.
C. Ensure that a chemotherapy-certified nurse is as-signed to care for the patient.
D. Carefully monitor the access site during the administration of the medication.
The nurse is reviewing Mr. N's (non-Hodgkin lymphoma) medication administration record and sees that the combination therapy aprepitant, dexamethasone, and ondansetron was administered during the last shift. What is the nurse most likely to ask to determine the efficacy of the therapy?
A. "After taking the medications, have you experienced any improvement in your energy level? Do you feel fatigued?"
B. "Are you having any feelings of nausea right now? When was the last time you vomited?"
C. "On a scale of 1 to 10, with 1 being the least and 10 being the worst, what number is your pain? Where is the pain located?"
D. "Have the medications improved your appetite? Are there special foods that you would prefer?"
The nursing student tells the team leader that Ms. C (bowel resection and colostomy) has just asked her to stay after the shift ends so that she can meet her granddaughter. What is the best response?
A. "What do you think your instructor would tell you to do?"
B. "It sounds like you really made a connection with Ms. C."
C. "What do you think about Ms. C's request?"
D. "Tell Ms. C that you have to go, but you will see her tomorrow."
The first-semester nursing student tells the team leader that her clinical assignment for the day is to take vital signs and obtain a patient history that will take about 1 or 2 hours to complete. Which patients would the leader recommend that she approach to fulfill her assignment? Select all that apply.
Mr. L (tracheostomy and partial laryngectomy)
Mr. U (pulmonary resection)
Ms. G (breast lumpectomy)
Mr. B (bladder cancer)
Ms. C (bowel resection and colostomy)
Mr. N (non-Hodgkin lymphoma)
The team leader is reviewing what the HCP has just prescribed for Mr. N (non-Hodgkin lymphoma). Which order will the team leader question?
A. Catheterize to obtain a urinalysis specimen.
B. Flush the IV saline lock every shift.
C. Monitor vital signs every 4 hours.
D. Administer filgrastim 5 mcg/kg subcutaneously every day.
Scenario: The nurse notes that Mr. U has tracheal deviation. Tension pneumothorax is suspected because of the sudden onset respiratory distress and the presence of the chest tube, which is a risk factor.
Which signs and symptoms would the nurse expect to observe with a tension pneumothorax? Select all that apply.
1. Tachypnea
2. Paradoxical chest movement
3. Hemoptysis
4. Profuse diaphoresis
5. Distended jugular veins
6. Decreased or absent breath sounds on the affected side
7. Bradycardia
8. Lateral or medial shift in the point of maximum impulse
9. Severe dyspnea
10. Progressive cyanosis
11. Extreme agitation
The team leader is working through the preoperative 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 the surgery. Can't I just take medication?" What is the priority nursing concept to consider in responding to Ms. G?
A. Functional Ability
B. Anxiety
C. Culture
D. Adherence
Mr. L (tracheostomy and partial laryngectomy) has been receiving 10 mg of IV morphine for pain. The HCP tells the nurse that Mr. L will be switched to oral (liquid) hydromorphone 5 mg. When the nurse checks an equianalgesic dose table, she sees that 10 mg of morphine equals 7.5 mg of hydromorphone. What would the nurse do?
A. Recognize that cross-tolerance is variable and titrating upward is required for safety.
B. Call the pharmacy to double-check that the equianalgesic dose is actually 7.5 mg.
C. Give the medication and tell the patient that he is receiving what was prescribed.
D. Question the HCP because the patient deserves to have adequate pain relief.
After the BCG treatment, the team leader delegates disposal of the fluid contents in Mr. B's (bladder cancer) urinary drainage bag to the AP. What instructions should be given to the AP?
A. "Wear a lead apron when you are emptying the drainage container."
B. "Discard the fluid in the toilet and disinfect the toilet with bleach for 6 hours."
C. "No special handling of the bag or its contents is required."
D. "Wear sterile gloves when you are handling the bag and its contents."
Ms. C (bowel resection and colostomy) is receiving epoetin alfa. Which laboratory result indicates that the HCP should be called to discontinue the medication?
A. White blood cell (WBC) count is 7,000 mm3 (7 x 109/L).
B. Blood glucose level is 85 mg/dl (12 mmol/L).
C. Hemoglobin is 12 g/dl (7.4 mmol/L).
D. Potassium level is 3.6 mEq/L (3.6 mmol/L).
Ms. C (bowel resection) 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." At this point, what is the priority nursing concept to consider in planning interventions for Ms. C?
Mobility
Functional Ability
Development
Stress and Coping
Scenario: The team leader-initiated discharge teaching with Mr. N. The teaching topics are signs and symptoms of infection and what should be reported to the HCP.
Which signs and symptoms would warrant calling the HCP right away? Select all that apply.
1. Insomnia
2. Chills and sweats
3. New onset pain
4. Changes in mental status
5. Flatulence
6. Stiff neck
7. Diarrhea
8. Burning with urination
9. Sore throat
10. Vomiting
11. Nasal congestion
12. One-time temperature of 99.4°F (37.4°C)
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