Chap 39 - 312
Which task does the nurse delegate to unlicensed assistive personnel (UAP)? Refer a client with a daily alcohol consumption of 12 beers for counseling Obtain a partial thromboplastin time from a saline lock on a client with a pulmonary embolism Report any bleeding noted when catheter care is given to a client with a history of hemophilia Perform a capillary fragility test to check vascular hemostatic function on a client with liver failure
Report any bleeding noted when catheter care is given to a client with a history of hemophilia The task the nurse delegates to the UAP is to report any bleeding when catheter care is given to a client with a history of hemophilia. Reporting findings during routine care is expected and required of unlicensed staff members.Referring a client for alcohol counseling, drawing a partial thromboplastin time, and performing a capillary fragility test are more complex and would be done by licensed nursing staff.
The nurse is reviewing complete blood count (CBC) data for a 76-year-old client. Which decreased laboratory value would be of greatest concern to the nurse because it is not age-related? Hemoglobin level Red blood cell (RBC) count Platelet (thrombocyte) count White blood cell (WBC) response
Platelet (thrombocyte) count The decreased laboratory value of the greatest concern to the nurse is the 76-year-old client's platelet count. Platelet counts do not generally change with age.Hemoglobin levels in men and women fall after middle age. Iron-deficient diets may play a role in this reduction. Total RBC and WBC counts (especially lymphocyte counts) are lower in older adults. The WBC count does not rise as high in response to infection in older adults as it does in younger people.
The nurse is assessing a client for hematologic risks. Which health history question would the nurse ask to determine if the risk cannot be reduced or eliminated? "Where do you work?" "Tell me what you eat in a day." "Does anyone in your family bleed a lot?" "Do you seem to have excessive bleeding or bruising?"
"Does anyone in your family bleed a lot?" To determine if hematologic risks exist while obtaining a health history from a client, the nurse asks if anyone in the client's family bleeds a lot. An accurate family history is important because many disorders that affect blood and blood clotting are inherited. Genetics cannot be changed.Work habits can be a risk, such as working near radiation, but these are behaviors that can be changed. Diet can affect risk, but it is a health behavior that can be changed.Excessive bleeding or bruising is a symptom, not a risk.
A client on anticoagulant therapy is being discharged. Which statement by the client indicates an understanding of the anticoagulants drug action? "It will thin my blood." "It is used to dissolve blood clots." "It should prevent my blood from clotting." "It might cause me to get injured more often."
"It should prevent my blood from clotting." The statement that shows the client understands anticoagulant drug action is, "it will prevent my blood from clotting." Anticoagulants work by interfering with one or more steps involved in the blood clotting cascade. Thus, these agents prevent new clots from forming and limit or prevent extension of formed clots.Anticoagulants do not cause any change in the thickness or viscosity of the blood.Anticoagulants do not dissolve clots, fibrinolytics do. Anticoagulants do not cause more injuries but may cause more bleeding and bruising when the client is injured.
The nurse is teaching a client who is preparing for discharge after a bone marrow aspiration. The nurse provides which discharge instructions to the client? "Inspect the site for bleeding every 4 to 6 hours." "Place an ice pack over the site to reduce the bruising." "Avoid contact sports or activity that may traumatize the site for 24 hours." "Take a mild analgesic, such as two aspirin, for pain or discomfort at the site."
"Place an ice pack over the site to reduce the bruising." Discharge instructions after a bone marrow include placing an ice pack over the site to reduce bruising. Ice to the site will help limit bruising and tissue damage during the first 24 hours after the procedure.The client must carefully monitor the site every 2 hours for the first 24 hours after the procedure. Contact sports and traumatic activity must be excluded for 48 hours, or 2 days. A mild analgesic is appropriate, but it needs to be aspirin-free. Acetaminophen (Tylenol) would be a good choice.
A client with a low platelet count asks the nurse, "Why are platelets important?" Which statement is the nurse's best response? "Platelets will make your blood clot." "Your platelets finish the clotting process." "Blood clotting is prevented by your platelets." "The clotting process begins with your platelets."
"The clotting process begins with your platelets." The nurse's best response to why platelets are important is that, "The clotting process begins with your platelets." Platelets begin the blood clotting process by forming platelet plugs, but these platelet plugs are not clots and cannot provide complete hemostasis.Platelets do not clot blood but are a part of the clotting process or cascade of coagulation. Platelets do not prevent the blood from clotting. Rather they function to help blood form clots. Platelets do not finish the clotting process, they begin it.
A client with anemia asks the nurse, "Do most people have the same number of red blood cells?" Which is the nurse's best response to the client? "Yes, they do." "No, they don't." "The number varies with gender, age, and general health." "You have fewer red blood cells because you have anemia."
"The number varies with gender, age, and general health." The nurse's best response to the client with anemia about most people having the same number of blood cells is, "The number varies with gender, age, and general health." This statement is the most educational and reasonable response to the client's question.Responding "yes, they do." and "no, they don't." are not educational statements. Although telling the client that people do not have the same number of RBCs is true, it is not informative, and there is a better answer. While it may be true that the client has fewer red blood cells because of anemia, it does not answer the client's general question.
The nurse is teaching a client about what to expect during a bone marrow biopsy. Which statement by the nurse accurately describes the procedure? "The doctor will place a small needle in your back and will withdraw some fluid." "You will be sedated during the procedure, so you will not be aware of anything." "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." "You will be alone because the procedure is sterile; we cannot allow additional people to contaminate the area."
"You may experience a crunching sound or a scraping sensation as the needle punctures your bone." When describing a bone marrow biopsy procedure to a client, it is accurate to describe a crunching sound or scraping sensation when the needle punctures the bone. Proper expectations minimize the client's fear during the procedure.A very large-bore needle is used for a bone marrow biopsy, not a small needle, and the puncture is made in the hip or in the sternum, not the back. A local anesthetic agent is injected into the skin around the site. The client may also receive a mild tranquilizer or a rapid-acting sedative (such as lorazepam [Ativan]) but will not be completely sedated. The nurse, or sometimes a family member, is available to the client for support during a bone marrow biopsy. The procedure is sterile at the site of the biopsy, but others can be present without contamination at the site.
A client with anemia asks the nurse, "Why am I feeling tired all the time?" What is the nurse's best response? "You are not getting enough iron." "When you are sick you need to rest more." "How many hours are you sleeping at night?" "Your cells are delivering less oxygen than you need."
"Your cells are delivering less oxygen than you need." The nurse's best response to the client complaining about feeling tired all the time is "Your cells are delivering less oxygen than you need." The single most common symptom of anemia is fatigue, which occurs because oxygen delivery to cells is less than is required to meet normal oxygen needs.While it may be true that the client isn't getting enough iron, it does not relate to the client's fatigue. The statement about the client needing rest because of being sick is simply not true. Although assessment of sleep and rest is good, it does not address the cause related to the diagnosis.
After reviewing the laboratory test results, the nurse calls the primary care provider about which client? A 52-year-old who had a hemorrhage with a reticulocyte count of 0.8% A 49-year-old with hemophilia and a platelet count of 150,000/mm3 (150 × 109/L) A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 (1.5 × 109/L) A 44-year-old prescribed warfarin (Coumadin) with an international normalized ratio (INR) of 3.0
A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 (1.5 × 109/L) The nurse calls the PCP about a 46-year-old client with a fever and a WBC of 1500/mm3 (1.5 × 109/L). This client is neutropenic and is at risk for sepsis unless interventions such as medications to improve the WBC level and antibiotics are prescribed.An elevated reticulocyte count in the 52-year-old is expected after hemorrhage. A platelet count of 150,000/mm3 (150 × 109/L) in the 49-year-old is normal. The INR of 3.0 in the 44-year-old indicates a therapeutic warfarin level.
The nurse is starting the shift by making rounds. Which client would the nurse assess first? A 52-year-old who just had a bone marrow aspiration and is requesting pain medication A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism A 47-year-old who had a Rumpel-Leede test and asks the nurse to "look at the bruises on my arm" A 42-year-old with a diagnosis of anemia who reports shortness of breath when ambulating down the hallway
A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism After rounds, the nurse would first assess the 59-year-old client who has a nosebleed and is getting heparin to treat a pulmonary embolism. The client with the nosebleed may be experiencing the bleeding as a result of excessive anticoagulation and must be assessed first for the severity of the situation.The client waiting for pain medication would be next on the nurse's "to do" list. Making clients wait for pain medication is not desirable, but in this scenario, the client who is bleeding is the higher priority. The client who had a Rumpel-Leede test and the client with anemia are more stable and can be assessed later. The Rumpel-Leede test is a tourniquet test used to determine the presence of vitamin C deficiency or thrombocytopenia.
A client has a bone marrow biopsy performed. What is the priority postprocedure nursing action? Inspect the site for ecchymosis Apply pressure to the biopsy site Send the biopsy specimens to the laboratory Teach the client to avoid vigorous activity
A client who had an emergency splenectomy The client who is at the highest risk for infection and sepsis is the client who had an emergency splenectomy. Removal of the spleen causes reduced immune function. Without a spleen, the client is less able to remove disease-causing organisms and is at increased risk for infection.A low red blood cell count with hemolytic anemia can contribute to a client's risk for infection, but this client is more at risk for low oxygen levels and ensuing fatigue. The liver plays a role in blood coagulation, so this client is more at risk for coagulation problems than for infection. Sickle cell anemia causes pain and discomfort because of the changed cell morphology, so acute pain, especially at joints, is the greatest threat to this client.
The nurse is caring for a group of hospitalized clients. Which client is at highest risk for infection and sepsis? A client with hemolytic anemia A client with cirrhosis of the liver A client who had an emergency splenectomy A client with recently diagnosed sickle cell anemia
A client who had an emergency splenectomy The client who is at the highest risk for infection and sepsis is the client who had an emergency splenectomy. Removal of the spleen causes reduced immune function. Without a spleen, the client is less able to remove disease-causing organisms and is at increased risk for infection.A low red blood cell count with hemolytic anemia can contribute to a client's risk for infection, but this client is more at risk for low oxygen levels and ensuing fatigue. The liver plays a role in blood coagulation, so this client is more at risk for coagulation problems than for infection. Sickle cell anemia causes pain and discomfort because of the changed cell morphology, so acute pain, especially at joints, is the greatest threat to this client.
Which client does the medical unit charge nurse assign to a licensed practical nurse (LPN)/licensed vocational nurse (LVN)? A client with chronic microcytic anemia associated with alcohol use A client scheduled for a bone marrow biopsy with conscious sedation A client with a history of a splenectomy and a temperature of 100.9°F (38.3°C) A client with atrial fibrillation and an international normalized ratio of 6.6
A client with chronic microcytic anemia associated with alcohol use The medical unit charge nurse assigns the LPN/LVN a client with chronic microcytic anemia related to alcohol use. Chronic microcytic anemia is not considered life-threatening and is within the skill level of an LPN/LVN.The client with a bone marrow biopsy with conscious sedation, a history of splenectomy and a temperature, and atrial fibrillation require more complex assessment or nursing care and would be assigned to RN staff members.
Which task does the nurse delegate to unlicensed assistive personnel (UAP) who is assisting with the care of a female client with anemia? Monitor the oral mucosa for pallor, bleeding, or ulceration Ask about the amount of blood loss with each menstrual period Check for sternal tenderness while applying fingertip pressure Count the respiratory rate before and after ambulating 20 feet (6 m)
Count the respiratory rate before and after ambulating 20 feet (6 m) Counting the respiratory rate before and after ambulation is within the scope of practice for a UAP. The UAP will report this information to the RN.Monitoring oral mucosa requires skilled assessment techniques and knowledge of normal parameters, asking the client about the amount of blood loss with each menstrual period, and checking for sternal tenderness would be done by the RN.
The nurse is assessing the nutritional status of a client with anemia. How does the nurse obtain information about the client's diet? Uses a prepared list and finds out the client's food preferences Asks the client to rate his or her diet on a scale of 1 (poor) to 10 (excellent) Has the client write down everything he or she has eaten for the past week Determines who prepares the client's meals and plans an interview with him or her
Has the client write down everything he or she has eaten for the past week The best way for the nurse to assess an anemic client's diet is to have the client write down everything he/she has eaten in the last week. Having the client provide a list of items eaten in the past week is the most accurate way to find out what the client likes and dislikes, as well as what the client has been eating. It will provide information about "junk" food intake, as well as protein, vitamin, and mineral intake.Determining food preferences from a prepared list provides information about what the client enjoys eating, not necessarily what the client has been eating. For instance, the client may like steak but may be unable to afford it. Rating scales are good for subjective data collection about some conditions such as pain, but the subjectivity of a response such as this does not provide the nurse with specific data needed to assess a diet. Interviewing the food preparer is time-consuming and poses several problems, such as whether a number of people are preparing meals, or if the client goes "out" for meals.
A newly admitted client has an elevated reticulocyte count. Which condition does the nurse suspect in this client? Leukemia Aplastic anemia Hemolytic anemia Infectious process
Hemolytic anemia The nurse suspects that the client has hemolytic anemia. An elevated reticulocyte count in an anemic client indicates that the bone marrow is responding appropriately to a decrease in the total red blood cell (RBC) mass and is prematurely destroying RBCs. Therefore, more immature RBCs are in circulation.A low white blood cell count is expected in clients with leukemia. Aplastic anemia is associated with a low reticulocyte count. A high white blood cell count is expected in clients with infection.
The nurse is assessing an adult client's endurance in performing activities of daily living (ADLs). What question would the nurse ask the client? "Can you prepare your own meals every day?" "How is your energy level compared with last year?" "Has your weight changed by 5 pounds (2.3 kg) or more this year?" "What medications do you take daily, weekly, and monthly?"
How is your energy level compared with last year?" The question the nurse needs to ask the client about endurance in performing ADLs is "How is your energy level compared with last year"? Asking the client how his or her energy level compares with last year is an activity exercise question that correctly assesses endurance compared with self-assessment in the past. It is most likely to provide data about the client's ability and endurance for ADLs.The client may never have been able to prepare his or her own meals, and the ability to prepare meals does not really address endurance. The question about weight change addresses nutrition and metabolic needs, rather than ADL performance. The question about how often the client takes medication addresses nutrition and metabolic needs and focuses on health maintenance through the use of drugs, not on the client's ability to perform ADLs.
A client is scheduled for a bone marrow aspiration. What is the priority nursing action before this procedure is performed? Hold the client's hand and ask about concerns. Review the client's platelet (thrombocyte) count. Verify that the client has given informed consent. Clean the biopsy site with an antiseptic or povidone-iodine (Betadine).
Verify that the client has given informed consent. The priority nursing action before a scheduled bone marrow aspiration is done is for the nurse to verify that the client has been given informed consent. A signed permit must be on the client's chart.Cleaning the biopsy site is done before the procedure, but this is not done until consent is verified. Cleaning the site will be done just before the procedure is performed. Holding the client's hand and offering verbal support may be done during the procedure, but the procedure cannot be completed until the consent is signed. Reviewing the client's platelet count is not imperative.
