HESI Case Study Laryngeal Cancer
Which question is most important for the RN to ask Mrs. Newman?
Have you had anything to eat or drink since midnight?
Which intervention will the PACU RN implement first?
Obtain Mrs. Newman’s vital signs
Which nursing intervention is most helpful to Mrs. Newman?
Ask Mrs. Newman if she would like to talk to someone who has had this surgery.
How should the ONS respond?
Explain that Mrs. Newman’s vocal cords will be removed and that she will not be able to sing.
Which question is important for the ONS to ask Mrs. Newman?
How much alcohol do you drink a week?
How should the ONS respond to help Mrs. Newman in her attempt to stop smoking?
What steps are you going to take to stop smoking?
A referral to which member of the interdisciplinary team will be most important for Mrs. Newman prior to surgery?
Which statement describes esophageal speech?
Swallowed air is used to create sound and words in a controlled belch
Which intervention will the nurse implement?
Determine is Mrs. Newman has any problems hearing or writing.
Which intervention should the RN implement?
Provide a bell that Mrs. Newman can ring as another means of communication
Which nursing intervention should the ICU RN implement?
Support the client’s head when moving the client in bed.
Which action should the nurse implement?
Document the finding and take no action
When anticipating these possible complications, the RN should place which equipment at Mrs. Newman’s bedside?
Several packages of sterile 4×4 gauze.
What action should the RN implement first?
Slip a gloved hand under the client’s neck
In which case is the laboratory result consistent with blood loss through hemorrhaging?
Hemoglobin 11.3 g/dl
Which action should the RN implement?
Provide Mrs. Newman with soft foods when she is eating for the first time after surgery
What action should the RN take regarding Mrs. Newman’s concern?
Explain the client that this is normal following this type of surgery.
Which action should the RN implement first?
Remove the tracheostomy dressing with clean disposable gloves.
What should the RN do before reinserting the inner cannula?
Tap or shake the inner cannula to remove excess moisture.
Which tasks should the RN delegate to the UAP?
-Empty the Foley catheter and record the output -Assist Mrs Newman with her bed bath
Which action should the charge nurse implement?
Instruct the primary nurse not to cut gauze for the tracheostomy dressing.
Which action should the night RN implement?
Complete a medication incident report.
How should the RN respond?
You were supposed to receive gentamicin, but you received ampicillin.
Which instructions should the RN provide to Mrs. Newman?
Take a deep breath, occlude the tracheostomy with your finger, cough and remove your finger.
Which instruction should the RN include?
Caution Mrs. Newman to take only tub baths.
Which intervention has highest priority prior to discharge?
Ensure that Mrs. Newman carries a special ID card
What is the best response by the RN?
Let’s sit down and discuss what you are worried about.
How should the RN respond?
Tell me more about what you mean by touching your wife?
Of the nursing diagnoses included in Mrs. Newman’s care plan, which one has the highest priority?
Ineffective airway clearance
Which explanation should the RN provide?
Humidified air will keep the mucous membranes and secretions moist.