HESI BREAST CANCER EXAM1HESI BREAST CANCER EXAM1HESI BREAST CANCER EXAM1HESI BREAST CANCER EXAM1HESI BREAST CANCER EXAM1HESI BREAST CANCER EXAM1HESI BREAST CANCER EXAM1HESI BREAST CANCER EXAM1HESI BREAST CANCER EXAM1
HESI BREAST CANCER EXAM1
At the community education program, Chandra learns that breast self-exam (BSE) is
best performed 7 days after the start of the menstrual flow when the breasts are least
engorged and tender. Since Chandra had a hysterectomy 5 years ago, she does not
have periods. She asks the nurse if she still needs to perform BSE, and so, when. -
CORRECT ANSWER-Select whatever day you can best remember to perform BSE
consistently every month
Chandra demonstrates BSE technique for the nurse using a practice model. She uses
her fingerpads and states that when lying down, her arm should be relaxed at her side.
What instructions should the nurse provide? - CORRECT ANSWER-When you are lying
down, your arm should be positioned over your head.
Another woman in the class said she had heard that there is a genetic test that would
diagnose breast cancer. What is the best response by the nurse? - CORRECT
ANSWER-A positive test for the BRCA 1 mutation identifies an increased risk for breast
cancer, but is not a certainty
While performing a BSE, Chandra discovers a lump.
After seeing her healthcare provider (HCP), Chandra is scheduled for a mammogram.
Chandra brings her 60 year old sister in law, Francie with her to the Women's Health
Center to learn about mammogram annually because she has no risk factors for breast
cancer, except that her father's sister had breast cancer when she was 50.
What intervention should the nurse implement first? - CORRECT ANSWER-Teach
Francie that even women with no identified risk factors are at risk
Francie states that she will schedule a mammogram and she asks the nurse if the x-ray
is painful. How should the nurse respond? - CORRECT ANSWER-You may experience
some discomfort, but only for a few minutes.
A mass is seen on Chandra's mammogram, and a follow-up stereotactic core needle
biopsy is performed. The tumor specimen is found to be cancerous. Chandra learns that
she has a cancerous tumor requiring surgery. She tells the nurse, "They make
mistakes. I know that happens. My specimen probably got switched with someone
else's, right?" - CORRECT ANSWER-"It's hard to believe that this is happening, isn't it?"
Chandra goes on to say, "I can control this. I will start exercising and I will change my
eating habits That will take care of it." How should the nurse respond? - CORRECT
ANSWER-"It sounds like you do not want to have surgery."
Which nursing diagnosis should be reflected in Chandra's plan of care? - CORRECT
ANSWER-Anticipatory grieving
,Chandra decides to have surgery and is scheduled for a modified radical mastectomy
with immediate abdominal myocutaneous flap reconstruction. A modified radical
mastectomy involves removal of breast tissue and lymph nodes, but it conserves the
pectoralis major muscle. The reconstruction involves the use of a flap of skin and
muscle from the abdomen to create a breast mound.
Chandra arrives at the Surgery Center 2 hours before her scheduled surgery. The nurse
confirms Chandra's NPO status. Chandra states, "I had a cracker this morning before I
came here. I am so nervous. I have to have this surgery today, or I will back out. Please
don't tell anyone."
What is the best response by the nurse? - CORRECT ANSWER-"To ensure your
safety, I need to notify the surgeon of the crackers you ate."
Which ethical principle has the greatest weight in the nurse's decision to inform
Chandra's surgeon about the snack? - CORRECT ANSWER-Nonmaleficence
The nurse confirms that Chandra has signed the informed consent for surgery, but
learns that Chandra does not understand the procedure for breast reconstruction that is
to be performed. What action should the nurse implement? - CORRECT ANSWER-
Notify the surgeon that further explanation of the procedure is necessary
After surgery, Chandra is admitted to the PACU for immediate postoperative
management.
Which nursing actions have the highest priority in the initial postoperative period?
(Select all that apply.) - CORRECT ANSWER-Observe the Jackson-Pratt drainage
device
Place head of the bed up at least 30 degrees with affected arm elevated on a pillow
Monitor vital signs and pulse oximetry
After Chandra is awake and stable, she is moved from the PACU to the regular post-op
unit. The nurse observes Chandra performing wrist flexion and extension exercises 4
hours after surgery.
What action should the nurse take? - CORRECT ANSWER-Encourage Chandra to
continue performing these exercises
The nurse enters Chandra's room and observes that a graduate nurse is assessing
Chandra's dressing while the unlicensed assistive personnel (UAP) takes postoperative
vital signs. The UAP is preparing to take Chandra's BP on her operative side because
there is an IV in the other arm.
,Which action should the nurse implement first? - CORRECT ANSWER-Advise the UAP
to immediately stop and obtain the blood pressure in the nonoperative arm
The nurse is discussing the situation with the graduate nurse and UAP. What should the
nurse emphasize in the discussion? - CORRECT ANSWER-Both the graduate nurse
and the UAP are at fault for the incorrect action of the UAP
Chandra seems happy and she tells the nurse that she received some good news. She
states that her tumor was negative for estrogen receptor sites. She continues, "That
means I have less likelihood of a recurrence or spread of the cancer."
What action should the nurse take first? - CORRECT ANSWER-Ask Chandra to clarify
how she learned this information so that a plan for further teaching can be developed.
Since Chandra's tumor is estrogen-receptor negative, she is not a candidate for
hormonal therapy. Tamoxifen (Nolvadex) is an antiestrogen drug that is often used to
prevent or treat recurrent breast cancer. Chandra states that a friend of hers took this
drug and has had no recurrence of her breast cancer. The nurse asks Chandra if her
friend experienced any problems when taking Tamoxifen (Nolvadex).
Which side effect is most often associated with Tamoxifen? - CORRECT ANSWER-Hot
flashes
Chandra is disappointed to learn that she will not benefit from hormonal therapy, but
she states that her friend indicated that taking the medication was like experience
menopause. How should the nurse respond? - CORRECT ANSWER-"The medication
decreases estrogen levels, which is what also causes the symptoms of menopause."
Because of her relatively young age, and the presence of a positive lymph node,
Chandra elects to take chemotherapy to reduce her risk of recurrence. The nurse
prepares Chandra for common adverse effects that she may experience.
Which adverse effects most often associated with antineoplastic chemotherapy used to
treat breast neoplasms should be included in this discussion? (Select all that apply.) -
CORRECT ANSWER-Diarrhea
Alopecia
A multi-lumen central line has been inserted and the nurse is preparing to administer a
dose of chemotherapy through the central line by first flushing the IV lumens. The nurse
notes that two of the four lumens do no flush easily.
What intervention is appropriate for the nurse to implement? - CORRECT ANSWER-
Notify the HCP that the central line is no longer functional
The nurse is aware that treatment with antineoplastic chemotherapeutic agents can
cause immunosuppression, which predisposes the client to infection. Which
, assessment finding would cause the nurse to suspect that an immunosuppressed client
has an infection? - CORRECT ANSWER-oral temperature of 99.5 F.
Chandra has completed her first round of chemotherapy. She calls the nurse to report
that she cut her arm on the operative side while doing yard work the previous day and
now her arm appears very swollen and tender.
Chandra is admitted to the hospital with a medical diagnosis of lymphedema and
possible cellulitis.
Which assessment findings led to the diagnosis of lymphedema? - CORRECT
ANSWER-Swelling and numbness in the affected arm.
Which nursing care measures will be most beneficial in the management of Chandra's
highest priority problem? (Select all that apply._) - CORRECT ANSWER-Apply a
sequential compression device
Elevate the affected arm
Chandra's prescription include vancomycin (vancocin) IV 1 g every 12 hours, obtain
peak and trough levels, ad acetaminophen 500 mg PO for fever > 100 F (37.8 C). When
is the best time to obtain the vancomycin serum trough level? - CORRECT ANSWER-
Fifteen minutes prior to administration of the next dose of the drug
It is time for Chandra's vancomycin (Vancocin). The vancomycin (Vancocin) IV 1 g is in
a 250 mL bag of 0.9% normal saline to be delivered in 1 hour. The IV tubing set is 15
drops/mL. How many drops per minute would the nurse set on the IV pump? (Enter the
numerical value only. If rounding is necessary, round to the whole number._) -
CORRECT ANSWER-63
250 x 15/60 minutes = 62.5 rounded to 63 drops/min
After receiving vancomysin (Vancocin) for 7 days, Chandra complains that her mouth is
painful when she swallows. When assessing her mouth, the nurse visualizes white,
patchy lesions. What is the most probable cause of this finding? - CORRECT
ANSWER-Candida superinfection
Chandra's resulting cellulitis from her injury and the complication of lymphedema are
resolved and she is discharged. She will continue with further chemotherapy, and she is
aware of the need for regular follow-up to assess for cancer recurrence both locally and
distally.
Chandra is asked to speak at a women's health symposium to share her experiences
with breast cancer. She works with the nurse to develop her presentation. The nurse
begins by discussing risk factors for breast cancer.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller MARIESTOPES1. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $7.19. You're not tied to anything after your purchase.
