Exam 4 Messer Essay Practice Questions Flashcards
List hospital care for a patient who is neutropenic secondary to chemotherapy. Include precautions, priorities, and things to avoid.
Neutropenic Precautions/Reverse
- Everyone that walks thru the door should wash their hands
- Have patients tell visitors this too!
- Private room
- Inspect skin every shift/as needed
- Mucous membranes, etc.
- Monitor for S/S of infection
- NO SHARED SUPPLIES
- No indwelling catheters
- Don’t reuse drinking cups (NO stagnant water)
- No fresh flowers
- No fresh fruit or veggies
- Cook meat completely
What are your priority assessment findings for a neutropenic patient?
Signs of infection - Fever - Tachycardia - Hypotension - Leukopenia Site Assessment: - Inspect any CVADs, IVs, etc Skin assessment - redness, swelling, warmth, pain, inflammation
The neutropenic patient is being discharged home.
List priorities for education regarding neutropenia.
Avoid crowds Avoid sick people Daily baths Hand washing Avoid Pet litter Cooking meat, veggies, fruits (pie only lol) Use condoms Don’t share things - Toothbrushes Monitor for signs of infection - Fever, skin breakdown (esp. mucous membranes)
Discuss care of a patient with a platelet count of 38,000. What can happen when a platelet count is this low? How will you avoid potential complications from this platelet count?
Platelet <50,000 → Prolonged bleeding Avoid any unnecessary pressure - Lift sheet - Pillow on top of head to avoid head bleed Avoid IM injections/Venipunctures Promotes Hemostasis - Apply pressure for 10 minutes for venipunctures - Use of Ice Assess IV sites Abdominal Girth measurement (internal bleeding) Avoid enemas, rectal temps, rectal tubes Fall Precautions Use Soft-Bristle toothbrush Use electric razors
NO:
Straight razors
NO dental floss
Nose blowing
What are your priority assessment findings for a patient with thrombocytopenia?
NEUROLOGIC ASSESSMENT! S/S of bleeding - Petechiae, bruising, tachycardia, hypotension Hemoccult (detects blood in stool) Skin assessment IV site assessment
The following day, the same patient’s platelet count is 19,000. How does this differ from the platelet count from the previous day (in terms of potential complication)? What will be your “recommendation” in your SBAR when you call the provider to report the value?
Platelets <20,000 → SPONTANEOUS BLEEDING RISK
More frequent bleeding assessments
Bleeding precautions
SBAR FOR PLATELET TRANSFUSION!
Your patient is receiving chemotherapy and has stomatitis (impaired oral mucous membranes related to stomatitis as manifested by painful mouth, painful eating and swallowing, thrush, and ulcerations.
List nursing assessment and interventions.
Cold therapy for mouth → AKA Oral Cryotherapy - Ice or popsicles Magic mouthwash (NA+-HCO3, lidocaine) Assess I&O Daily weights Albumin levels Use Soft toothbrush No mouthwash
INDIVIDUALIZE DIET BASED ON PATIENT PREFERENCE!
Dietician referral
Your patient has severe fatigue related to chemotherapy. List nursing interventions for this patient.
Ambulation
Set priorities
- Daily bath (can’t not do this, so prioritize it; shower chair may help)
Rest periods
Teach them to ask for help
Have patient assign an advocate (family member, etc.) for when they’re too fatigued
List specific lab values associated with the following (include all values, including defining values and critically low values).
Other than chemotherapy, what else might cause these values to be low?
Neutropenia
1500-5000 normal
Neutropenic precautions: ANC >500 OR <1000 w/ fever present or opportunistic infection
Thrombocytopenia
<50,000 → Prolonged bleeding
<20,000 → Spontaneous bleeding
Fatigue
Hemoglobin
Other causes of low lab values:
- Cancer itself
- Radiation treatment
- Bone metastasis
Discuss breast cancer screening (age recommendations).
What are educational priorities?
What is the role of self-breast exams in breast cancer screening?
Mammograms?
How is breast cancer diagnosed?
This is very individualized
Average risk → Mammograms recommended age >40
High-risk → MRI/US every year
- Get screened 10 years before your first-degree relative developed breast cancer
SBE’s:
- Know your normal
- Perform Same time every month
Diagnosis → Biopsy
You are working on a post-surgical women’s unit. You are caring for Mary who is recovering from a right radical mastectomy with a lymph node dissection. What restrictions should be in place for Mary?
No BPs, IVs, or venipuncture on the right side
Put a SIGN OVER the BED
BEST PRACTICE: ASK THE PATIENT!! → AND EDUCATE the patient to advocate themselves
Double → BP on leg
On post-op day 1, Mary tells you she has always been very active and wants to start exercising today. Discuss appropriate activity for Mary.
- Walking :)
- IS
- Consult w/ Physical therapy
You are discharging Mary and creating a plan for her activity progression.
What activities can she engage in once her drains are out?
Make any further recommendations Mary will need during her recovery.
Start arm exercises
Stop when it hurts
No arms over your head
Recommendations:
YWCA ENCORE
YMCA Live Strong
List risk factors for breast cancer.
- Age
- Genetics (BRCA)
- 1st Degree relative
- Female at birth
- Environmental
- Alcohol
- Null Parity
- Early menstruation/ Late menopause
- Estrogen use Birth Control; HRT
- Obesity
List risk factors for colon cancer.
- Age
- Obesity
- Ulcerative colitis
- Low fiber diet (high fat)
- Alcohol
- Smoking
- Genetics
- Sedentary lifestyle
Discuss screening tools for colorectal cancer (include ages).
What is the gold standard for colorectal cancer screening?
Why is a fecal occult test helpful in screening for colorectal cancer?
What are the limitations of the test?
Colonoscopy Gold Standard for Screening
Age recommendations:
- Average risk: 45 yr
- High risk: 10 years before 1st-degree relative
- Crohn’s Disease: annual colonoscopy (also tells us if the disease is being managed)
Fecal occult → detects blood
LOTS OF FALSE NEGATIVES → precancerous polyps that don’t bleed
You are precepting on a unit and the nurse tells you he will be assessing a patient with a new colostomy. As he looks at the stoma, he tells you it looks exactly as it should.
What would you expect the stoma to look like?
Beefy red
Skin intact
Budded ~3/4 above the skin; Not retracted/protracted
For the same patient (new colostomy), what would you expect the output to look like on each of the following days?
Post-op day 1?
Post-op days 2-3?
Post-op day 7 if the colostomy is in ascending colon?
Post-op day 7 if the colostomy is in transcending colon?
Post-op day 7 if the colostomy is in descending colon?
What if this is an ileostomy? What would output look like?
Post-op day 1? → Sanguineous → Serosanguineous
Post-op days 2-3? → A little bit of stool
Post-op day 7 if the colostomy is in ascending colon?
→ more liquid
Post-op day 7 if the colostomy is in transcending colon?
→ pasty
Post-op day 7 if the colostomy is in descending colon?
→ formed
What if this is an ileostomy? → liquid
A patient visits the clinic with a colostomy he has had for several months and reports no output for a couple of days. What are your priority assessments?
BIGGEST PRIORITY IS IDENTIFYING IF THIS IS AN OBSTRUCTION!
- Do you have pain?
- What have you eaten?
- Has this happened before?
You are caring for a patient with colorectal cancer who reports increased abdominal pain. When you assess the patient, you note there are no bowel sounds. This is a change from earlier when you heard high-pitched bowel sounds and could see movement in the lower abdomen. What do you suspect and what are you going to do?
COMPLETE OBSTRUCTION
Partial obstruction was occurring first indicated by the high-pitched sound bowel sounds.
WHAT TO DO:
Ensure pt is stable: pain assessment, vitals signs, call RR (rapid response) or provider
Imaging → contact provider
A patient is transferred to the Med-Surg unit after a lengthy stay in the ICU for sepsis and multi-organ failure. The patient starts complaining of severe abdominal pain and is clutching his stomach and is in a fetal position. Upon assessment, the nurse finds the abdomen is extremely firm and the patient has rebound tenderness.
What action should the nurse take?
Suspected peritonitis, perforated bowel
Call provider, RR (rapid response)
Get your patient stable and ready for transport
A patient is admitted to the Med-Surg unit from the ER with a suspected upper GI bleed. Under what circumstances would the following occur?
(Expected/Not likely, explanation..)
Nasogastric tube → Hematemesis → Melena → Nausea → Regular diet → Order for 2 units of packed RBCs → Order for fresh frozen plasma → EGD ordered → Golytely ordered → Urea breath test →
Nasogastric tube → Not likely
Hematemesis → Expected
Melena → Probably lower
(I think she means lower GI Bleed…)
Nausea → Expected; could also be other things
Regular diet → AFTER GI bleed is resolved; clear liquids first & advance as tolerated
Order for 2 units of packed RBCs → If excessive bleeding is occurring; low Hgb or dropping Hgb (transfuse if Hgb <7 g/dL)
Order for fresh frozen plasma → Yes if PLTs are low b/c several RBC transfusions were given and we need to balance; PT/INR abnormalities; on Warfarin (Coumadin) or other anticoagulants
EGD ordered → Expected; typically what we do to figure out where the bleed is so we can stop it
Golytely ordered → R/O an upper GI bleed, or previously fixed an upper GI bleed and there are signs of active bleeding from the bottom (Golytely = polyethylene glycol used for gut prep before Barium x-ray)
Urea breath test → H. pylori
Risk Factors for GERD, Gastritis, and/or PUD? (Can be >1).
A) A patient with COPD who takes oral prednisone daily.
B) Professional athlete who takes ibuprofen 400 mg twice a day for pain relief.
C) An individual who drinks 8-10 alcoholic drinks a week.
D) Patient who is infected with H. Pylori
E) Patient with complaints of dyspepsia
F) Patient who is overweight and has a “beer belly”
G) An 88-year old patient with extensive cardiac disease and has been taking 325mg Bayer Aspirin daily for the last 10 years.
H) Patient has a known hiatal hernia
A) A patient with COPD who takes oral prednisone daily.
→ GERD, Gastritis, & PUD
B) Professional athlete who takes ibuprofen 400 mg twice a day for pain relief.
→ Gastritis & PUD
C) An individual who drinks 8-10 alcoholic drinks a week.
→ GERD, Gastritis, & PUD
D) Patient who is infected with H. Pylori
→ Gastritis & PUD
E) Patient with complaints of dyspepsia
→ NOT a Risk factor, but a SYMPTOM
F) Patient who is overweight and has a “beer belly”
→ GERD, Gastritis, & PUD
G) An 88-year old patient with extensive cardiac disease and has been taking 325mg Bayer Aspirin daily for the last 10 years.
→ GERD, Gastritis, & PUD
H) Patient has a known hiatal hernia.
→ GERD
A patient has severe GERD. What conversation would occur about his diet?
Avoid irritating foods
Eat smaller portions
Don’t eat right before bed
Managing weight, if indicated
A patient had an EGD and is found to be positive for H.Pylori.
What information would you share with the patient about the significance of H. Pylori?
What would you expect to happen?
H. Pylori contributes to Gastritis and PUD; it can injure the epithelium, but when someone is symptomatic, it should be treated. Can also cause gastric cancers.
We want to get rid of it and treat ulcers
Triple therapy: PPI + 2 antibiotics to avoid the development of resistant bacteria/drug-resistant bacteria
Quadruple therapy: triple therapy + Pepto
When would the following procedures be done? (Gastritis, GERD, PUD, or both)
A) EGD →
B) Partial gastrectomy →
C) Nissen fundoplication →
D) Pylorplasty: surgery that widens the opening in the pylorus →
E) Vagotomy: removal of part of the vagus nerve that stimulates stomach acid production. →
F) Stretta procedure:catheter-guided delivery of electromagnetic waves to lower esophageal sphincter; heats the tissue causing LES to stiffen. →
A) EGD → GERD & PUD w/ hematemesis
B) Partial gastrectomy → GERD & PUD for removal of persistent ulcers (also stomach
cancer)
C) Nissen fundoplication → severe GERD
D) Pylorplasty: surgery that widens the opening in the pylorus → PUD
E) Vagotomy: removal of part of the vagus nerve that stimulates stomach acid production. → Gastritis, GERD, PUD
F) Stretta procedure:catheter-guided delivery of electromagnetic waves to lower esophageal sphincter; heats the tissue causing LES to stiffen. → GERD
Why do almost all of our surgical patients receive a proton pump inhibitor?
To prevent stress ulcers and reduce risk of aspirating acidic stomach contents.
A patient is admitted to the hospital with severe gastritis related to the use of Goody’s powder for chronic migraine headaches. He is being prepared for a partial gastrectomy tomorrow.
What conversation would you have with this patient about the use of Goody’s powder and pain management for migraines?
Goody’s powder contains Aspirin, caffeine, and acetaminophen.
Assess:
how often do they take it?
Patient teaching:
Need to stop taking it before surgery.
We need to ask the provider to maybe send this patient to a neurologist for better migraine management
A patient reports waking up at 2 am nightly with symptoms of a bitter taste in her mouth
that sometimes causes a coughing fit.
What is happening here and what interventions might be helpful for this patient?
Regurgitation- GERD Raise HOB Take prophylactic antacids Know what foods trigger Sxs Don’t eat before bed. Treat OSA (?) if they have it
A patient reports that her GERD symptoms have gotten worse since she started working in the landscaping business planting flowers.
What could be causing this?
Bending over Is probably making this worse or restrictive clothing…
Avoid irritating foods, smaller meals, and
wait a little bit after lunch to go back to gardening; wear loose-fitting clothes
Suggest Prophylactic Medication
A woman who is 8-months pregnant complains about GERD symptoms.
How would you respond?
Resolves after delivery-
Don’t say, “you only have four more weeks of this.”
Provide GERD education on ways to prevent
A patient is post-operative following a Nissen-fundoplication surgery.
What post-operative care is key?
Difficulty swallowing for up to six weeks
No bending
No lifting more than 10 lbs
NO DRINKING THROUGH A STRAW
Clear liquid diet at 1st; advance as tolerated
Small meals
Be aware of diet choices–avoid irritating foods
Avoid gas-producing foods
- no gum
- no sweets
The nurse notes melena in a patient post EGD procedure today with clipping done of a gastric ulcer.
What action should the nurse take?
Need to further assess!
- It May just be the passage of blood from the upper GI bleed, but need to assess
and manage accordingly.
VS’s?
how much blood?
Assess Hg?
If unstable:
IV access
contact GI provider
Prepare for administration of blood products, fluids, and drugs to manage
But this could also be passage of blood from a previous bleed….
A 60-year-old male patient presents to the ED with complaints of chest pain. You know that it could be GI-related (GERD, indigestion) or cardiac in nature.
What should be done?
ASSUME THE WORST → Cardiac/ACS
Initiate chest pain protocol
VS’s, 12-lead, cardiac enzymes, OLD CARTS, MONA, antacids, …
The nurse is preparing a patient for an EGD because Barrett’s Esophagus is expected.
How does the nurse explain what Barrett’s Esophagus is?
What are the concerns with this finding?
GERD complication
Barrett’s esophagus is an epithelial adaptation to better withstand acid reflux, but the concern is it’s precancerous!
If not diagnosed yet, get GERD dx
What are the manifestations of bowel perforation and subsequent peritonitis?
Abdominal pain
Rigid board-like abdomen
Signs of shock and infection
- fever
- diaphoresis/clammy
- signs of poor perfusion
-low urinary output
-confusion
- tachycardia
- low blood pressure
