Ch. 29 Assessment of Hematologic System

Nursing care for a patient immediately after a bone marrow biopsy and aspiration includes (select all that apply) a. administering analgesics as necessary b. preparing to administer a blood transfusion c. instructing on need to lie still with a sterile pressure dressing intact d. monitoring vital signs and assessing the site for excess drainage or bleeding e. instructing on the need for preprocedure and postprocedure antibiotic medications

a. administering analgesics as necessary c. instructing on need to lie still with a sterile pressure dressing intact d. monitoring vital signs and assessing the site for excess drainage or bleeding Rationale: The needle aspiration or biopsy site is covered with a sterile pressure dressing. Monitor the patient's vital signs until stable, and assess the site for excess drainage or bleeding. If bleeding is detected, advise the patient to lie on the side for 30 to 60 minutes to maintain pressure on the site. If the bed is too soft, have the patient lie on a rolled towel to provide additional pressure. Analgesics for postprocedure pain may be administered. Soreness over the puncture site for 3 to 4 days after the procedure is normal.

Significant information obtained from the patient's health history that relates to the hematologic system includes a. jaundice b. bladder surgery c. early menopause d. multiple pregnancies

a. jaundice Rationale: Jaundice is a common symptom that occurs with hematologic abnormalities. Jaundice is related to an accumulation of bile pigment that is caused by rapid or excessive hemolysis or liver damage.

When reviewing laboratory results of an older patient with an infection, the nurse would expect to find a. minimal leukocytosis b. decreased platelet count c. increased hemoglobin and hematocrit levels d. decreased erythrocyte sedimentation rate (ESR)

a. minimal leukocytosis Rationale: During an infection, an older adult may have only a minimal elevation in the total WBC count. This laboratory finding suggests a diminished bone marrow reserve of granulocytes in older adults and reflects possible impaired stimulation of hematopoiesis

If a lymph node is palpated, what is a normal finding? a. Hard, fixed nodes b. Firm, mobile nodes c. Enlarged, tender nodes d. Hard, nontender nodes

b. Firm, mobile nodes Rationale: Ordinarily, lymph nodes are not palpable in adults. If a node is palpable, it should be small (0.5 to 1 cm), mobile, firm, and nontender to be considered a normal finding.

An anticoagulant such as warfarin (Coumadin) that interferes with prothrombin production will alter the clotting mechanism during a. platelet aggregation b. activation of thrombin c. the release of tissue thromboplastin d. stimulation of factor activation complex

b. activation of thrombin Rationale: Warfarin inhibits the effective synthesis of vitamin K-dependent clotting factors: II (prothrombin), VII (stable factor), IX (Christmas factor), and X (Stuart-Prower factor) in the extrinsic pathway. Thrombin is not activated, and coagulation is interrupted in the final common pathway of the clotting cascade. Without thrombin activation, fibrinogen is not converted to fibrin, and blood clotting does not occur.

Malignant disorders that arise from granulocytic cells in the bone marrow will have the primary effect of causing a. risk for hemorrhage b. altered oxygenation c. decreased production of antibodies d. decreased phagocytosis of bacteria

d. decreased phagocytosis of bacteria Rationale: The primary function of granulocytes is phagocytosis, a process by which white blood cells (WBCs) ingest or engulf any unwanted organism, such as bacteria, and then digest and kill it. In malignant disorders, these phagocytic cells are often reduced in number and function.

An individual who lives at a high altitude may normally have an increased Hgb and RBC count because a. high altitudes cause vascular fluid loss, leading to hemoconcentration b. hypoxia caused by decreased atmospheric O2 stimulates erythropoiesis c. the function of the spleen in removing old RBCs is impaired at high altitudes d. impaired production of leukocytes and platelets leads to proportionally higher red cell counts

b. hypoxia caused by decreased atmospheric O2 stimulates erythropoiesis Rationale: Normal physiologic increases in the red blood cell (RBC) count occur at high altitudes. At high altitudes, less atmospheric weight pushes air into the lungs; the partial pressure of O2 is thereby decreased, which causes hypoxia. Erythropoiesis is stimulated by hypoxia and controlled by erythropoietin, a glycoprotein growth factor synthesized and released by the kidneys. Erythropoietin stimulates the bone marrow to increase erythrocyte production.

You are taking care of a male patient who has the following laboratory values from his CBC: WBC 6.5x10^3/uL, Hgb 13.4 g/dL, Hct 40%, platelets 50x10^3/uL. What are you MOST concerned about? a. Your patient is neutropenic. b. Your patient has an infection. c. Your patient is at risk for bleeding. d. Your patient is at fall risk due to his anemia.

c. Your patient is at risk for bleeding. Rationale: The patient complete blood cell count (CBC) has normal parameters except for the platelet count, which is below normal.

While assessing the lymph nodes, the nurse should a. apply gentle, firm pressure to deep lymph nodes b. palpate the deep cervical and supraclavicular nodes last c. lightly palpate superficial lymph nodes with the pads of the fingers d. use the tips of the second, third, and fourth fingers to apply deep palpation

c. lightly palpate superficial lymph nodes with the pads of the fingers Rationale: To assess superficial lymph nodes, lightly palpate the nodes, using the pads of your fingers. Then gently roll the skin over the area and concentrates on feeling for possible lymph node enlargement.