Lewis- Ch. 30: Nursing Assessment: Hematologic System
A nurse reviews the lab report of a patient that shows the white blood cell count is 15 × 10{9}/L. Which condition is the patient likely experiencing? 1 Infection 2 Neutropenia 3 Risk of bleeding 4 Thrombocytopenia
1 (A patient's medical report shows the white blood cell count to be 15 × 10{9}/L. The normal range for a white blood cell count is between 4 × 10{9}/L to 11 × 10{9}/L. Elevations in white blood cell count are associated with infection, because white blood cells (WBCs) are immune cells. Neutropenia is a condition in which the absolute neutrophil count (ANC) is less than 1000 cells/μL. It does not increase the risk of bleeding. Thrombocytopenia is a condition in which platelet counts fall below 100,000/μL. Text Reference - p. 626)
The nurse is reviewing the hematologic study report of a 70-year-old patient. Which finding should the nurse consider normal for this patient? 1 Decreased serum iron 2 Decreased ferritin 3 Increased total iron-binding capacity 4 Decreased erythrocyte sedimentation rate (ESR)
1 (As a result of the aging process, hematologic values may change but are considered normal for the older adult. The serum iron level may be decreased. Ferratin levels are increased, total iron-binding capacity may be decreased, and ESR is increased. Text Reference - p. 619)
Which coagulation factor converts prothrombin to thrombin? 1 Factor X 2 Factor XI 3 Factor XII 4 Factor XIII
1 (Factor X is also called Stuart-Prower factor. Its action is to convert factor II, prothrombin, to thrombin. Factor XI is known as plasma thromboplastin antecedent. Factor XI activates Christmas factor in the presence of calcium ions. Hageman factor is another name for factor XII. Hageman factor activates factor IX to stimulate the intrinsic pathway. Factor XIII is also known as fibrin-stabilizing factor. Fibrin-stabilizing factor cross-links fibrin strands. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question. Text Reference - p. 618)
On assessment, a nurse finds that a patient has a smooth and shiny tongue surface. The oral mucosa is thin and appears red from decreased papillae. The patient has a hemoglobin level of 8.0 mg/dL. What is the likely diagnosis of the patient? 1 Pernicious anemia 2 Jaundice 3 Epistaxis 4 Lymphadenopathy
1 (Pernicious anemia manifests as low hemoglobin levels. The signs may include a smooth and shiny tongue surface and a thin mucosa that appears red due to decreased papillae. Yellow appearance of the sclera is a symptom of jaundice due to deposition of bilirubin. Spontaneous bleeding from the nares is a sign of epistaxis. Lymph nodes which are enlarged (greater than 1 cm) and tender to touch are symptoms of lymphadenopathy. Text Reference - p. 622)
The laboratory report of an elderly patient shows slight decrease in the mean corpuscular hemoglobin concentration. The nurse recognizes that what could be the reason for the decrease? 1 Aging 2 Microcytosis 3 Spherocytosis 4 Erythrocytosis
1 (The red blood cell plasma membranes are more fragile in an older person. This may account for a slight decrease in the mean corpuscular hemoglobin concentration (MCHC) of the red blood cells. Microcytosis is a condition in which the mean corpuscular hemoglobin level is decreased. Spherocytosis is a condition in which the corpuscular hemoglobin concentration increases. Erythrocytosis is a disease state in which the proportion of blood volume occupied by red blood cells increases. Text Reference - p. 625)
Which organ acts as a site for the synthesis of iron carrier proteins? 1 Liver 2 Spleen 3 Bone marrow 4 Macrophages
1 (Transferrin is a plasma protein that acts as a carrier for iron; the synthesis of this protein occurs in the liver. The spleen is the site for the synthesis of red blood cells during fetal development. Bone marrow is the site for maturation of red blood cells. Macrophages help to store ferritin, a storage form of iron. Text Reference - p. 616)
Which process is stimulated by hypoxia? 1 Hemolysis 2 Erythropoiesis 3 Hematopoiesis 4 Thrombocytosis
2 (Erythropoiesis is the production of red blood cells. A patient with a low red blood cell count will have low levels of oxygen, resulting in hypoxia. Therefore, erythropoiesis is stimulated to increase the available oxygen. Hemolysis is degradation of red blood cells, which occurs due to bacterial infection or autoimmune disorders. Hematopoiesis is the formation of blood cell components and is not associated with hypoxia. Thrombocytosis is an increase in the platelet count, which is seen in response to bleeding. Text Reference - p. 615)
What is the first process that occurs during normal hemostasis? 1 Lysis of the clot 2 Vascular response 3 Plasma clotting factor 4 Platelet plug formation
2 (Hemostasis is a process that arrests bleeding. The vascular response is the first response to bleeding. Lysis of a clot is the counter mechanism to keep blood in its fluid state. This process occurs after the clot formation. Plasma clotting factors bind to platelet plugs and form a complex clot. The platelets aggregate to form a clump, which reduces the risk of bleeding. However, this takes place after vascular response. Text Reference - p. 616)
A patient with anemia presents with a heart rate of 120 beats/minute. As what should the nurse document the heart rate? 1 Bradycardic 2 Tachycardic 3 Hypertensive 4 Hypotensive
2 (If a patient is tachycardic, the heart rate is above 100 beats/minute, which may occur in anemic patients as a compensatory mechanism to increase cardiac output. If a patient is bradycardic, the heart rate is below 60 beats/minute. Hypertensive and hypotensive refer to blood pressure readings, not the heart rate. STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress. Text Reference - p. 624)
Which cells ingest dead cells, tissue debris, and defective red blood cells? 1 Basophils 2 Eosinophils 3 Monocytes 4 Thrombocytes
3
A blood type and crossmatch has been prescribed for a male patient who is experiencing an upper gastrointestinal bleed. The results of the blood work indicate that the patient has type A blood. Which description explains what this means? 1 The patient can be transfused with type AB blood. 2 The patient may only receive a type A transfusion. 3 The patient has A antigens on his red blood cells (RBCs). 4 Antibodies are present on the surface of the patient's RBCs
3 (An individual with type A blood has A antigens, not A antibodies, on his RBCs. An AB transfusion would result in agglutination, but he may be transfused with either type A or type O blood. Text Reference - p. 628)
What is the primary function of red blood cells (RBCs)? 1 Initiating the blood coagulation process 2 Ingesting and destroying unwanted organisms 3 Transporting oxygen and carbon dioxide 4 Protecting the body against infections and foreign invaders
3 (Red blood cells (RBCs) transport oxygen and carbon dioxide by binding those chemicals to the iron component of hemoglobin. Platelets initiate the blood coagulation process. Phagocytosis (the process of engulfing and destroying unwanted organisms) is the primary function of granular leukocytes. Leukocytes play an important role in protecting the body against infections. Text Reference - p. 615)
Which term refers to the resident macrophages in the liver? 1 Mast cells 2 Osteoclasts 3 Kupffer cells 4 Megakaryocyte
3 (Special names are given to macrophages that reside in different tissues. The resident macrophages in the liver are called Kupffer cells. Mast cells are similar to basophils and are present in the connective tissue. Osteoclasts reside in the bone. A megakaryocyte is a differentiated stem cell that fragments into platelets. Text Reference - p. 616)
A patient's complete blood count is RBC 1.8 × 10{6}/μL, WBC 2 × 10{9}/L, platelets 90 × 10{9}/L. How should the nurse interpret the test results? 1 Leukopenia 2 Neutropenia 3 Pancytopenia 4 Thrombocytopenia
3 (The patient's complete blood count is suppressed. There is a marked decrease in the number of RBCs, WBCs, and platelets. This condition is called pancytopenia. Leukopenia is a condition in which white blood cells count less than 4000/μL. Neutropenia is a condition in which the absolute neutrophil count (ANC) is less than 1000 cells/μL. Thrombocytopenia is condition in which platelet counts falls below 100,000/μL. Text Reference - p. 625)
When assessing laboratory values of a patient admitted with septicemia, what should the nurse expect to find? 1 Increased platelet count 2 Decreased red blood cell count 3 Decreased erythrocyte sedimentation rate (ESR) 4 Increased bands in the white blood cell (WBC) differential (shift to the left)
4 (When infections are severe, such as in septicemia, more granulocytes are released from the bone marrow as a compensatory mechanism. To meet the increased demand, many young, immature polymorphonuclear neutrophils (bands) are released into circulation. WBCs usually are reported in order of maturity (initially with the less mature forms on the left side of a written report). Hence, the term "shift to the left" is used to denote an increase in the number of bands. Thrombocytosis occurs with inflammation and some malignant disorders. A decreased number of red blood cells indicates anemia. A decreased ESR is not indicative of septicemia. Text Reference - p. 627)
A client has a bone marrow biopsy done. Which nursing intervention is the priority postprocedure? A. Applying pressure to the biopsy site B. Inspecting the site for ecchymoses C. Sending the biopsy specimens to the laboratory D. Teaching the client about avoiding vigorous activity
A. Applying pressure to the biopsy site
The nurse is caring for a client who is receiving heparin therapy. How does the nurse evaluate the therapeutic effect of the therapy? a. Evaluate platelets. b. Monitor the partial thromboplastin time (PTT). c. Assess bleeding time. d. Monitor fibrin degradation products.
ANS: B The PTT assesses the intrinsic clotting cascade. Heparin therapy is monitored by the PTT. Platelets are monitored by the platelet count laboratory value, bleeding time evaluates vascular and platelet activity during hemostasis, and fibrin degradation products help assess for fibrinolysis.
The nurse is assessing the following laboratory results of a client before discharge. Which instruction does the nurse include in this client's discharge teaching plan? Test Result Hemoglobin 15 g/dL Hematocrit 45% White blood cell (WBC) count 2000/mm3 Platelet count 250,000/mm3 a. "Avoid contact sports." b. "Do not take any aspirin." c. "Eat a diet high in iron." d. "Perform good hand hygiene."
ANS: D A normal WBC count is 5000 to 10,000/mm3. A white blood cell count of 2000/mm3 is low and makes this client at risk for infection. Good handwashing technique is the best way to prevent the transmission of infection. The other laboratory results are all within normal limits.
A confused patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse should contact the patient's family member to sign a consent form before the a. ABO blood typing. b. bone marrow biopsy. c. abdominal ultrasound. d. complete blood count (CBC).
B Bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent by the patient or family.
When caring for a patient with a chronic iron deficiency anemia, the nurse will assess for a. yellow-tinged sclerae. b. shiny, smooth tongue. c. numbness of the extremities. d. gum bleeding and tenderness.
B Loss of the papillae of the tongue occurs with chronic iron deficiency. Scleral jaundice is associated with hemolysis, gum bleeding and tenderness occur with thrombocytopenia or neutropenia, and extremity numbness is associated with vitamin B12 deficiency or pernicious anemia.
The nurse is assessing a client for hematologic function risks and seeks to determine whether there is a risk that cannot be reduced or eliminated. Which clinical health history question does the nurse ask to obtain this information? A. "Do you seem to have excessive bleeding or bruising?" Incorrect B. "Does anyone in your family bleed a lot?" Correct C. "Tell me what you eat in a day." D. "Where do you work?"
B. "Does anyone in your family bleed a lot?"
The nurse is reviewing complete blood count (CBC) data for a 76-year-old client. Which decreased value causes concern because it is not age-related? A. Hemoglobin level B. Platelet (thrombocyte) count C. Red blood cell (RBC) count D. White blood cell (WBC) response
B. Platelet (thrombocyte) count
The history and physical for a newly admitted patient states that the complete blood count (CBC) shows a "shift to the left." The nurse will plan to monitor the patient for a. cool extremities. b. pallor and weakness. c. elevated temperature. d. low oxygen saturation.
C The term shift to the left indicates that the number of immature polymorphonuclear neutrophils, or bands, is elevated and is a sign of severe infection. There is no indication that the patient is at risk for hypoxemia, pallor/weakness, or cool extremities.
In the patient who had an intraoperative hemorrhage 12 hours ago, the nurse would expect to find hematology results indicating a. a hematocrit of 45%. b. a hemoglobin of 13.2 g/dL. c. a decreased white blood cell (WBC) count. d. an elevated reticulocyte count.
D Hemorrhage causes the release of more immature RBCs from the bone marrow into the circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.
The nurse is caring for a client who had a bone marrow aspiration. The client begins to bleed from the aspiration site. Which action does the nurse perform? a. Apply external pressure to the site. b. Elevate the extremities. c. Cover the site with a dressing. d. Immobilize the leg.
NS: A All these options could be done after a bone marrow aspiration and biopsy. However, the most important action when bleeding occurs is to apply external pressure to the site until hemostasis is ensured. The other measures could then be carried out.
The nurse is obtaining the health history of a client who has iron deficiency anemia. Which factor in this client's history does the nurse correlate with this diagnosis? a. Eating a meat-free diet b. Family history of sickle cell disease c. History of leukemia d. History of bleeding ulcer
ANS: A A diet high in protein and iron helps keep the client's levels of iron within normal limits. Meat is a good source of protein and iron. A bleeding ulcer could cause anemia but would not cause iron deficiency. Sickle cell disease causes sickle cell anemia. Leukemia causes a decrease in white blood cells.
The nurse is administering a prescribed fibrinolytic to a client who is having a myocardial infarction (MI). Which adverse effect does the nurse monitor for? a. Bleeding b. Orthostatic hypotension c. Deep vein thrombosis d. Nausea and vomiting
ANS: A A fibrinolytic lyses any clots in the body, thus causing an increased risk for bleeding. Fibrinolytic therapy does not place the client at risk for hypotension, thrombosis, or nausea and vomiting. pg 861
The nurse is teaching a client about what to expect during a bone marrow biopsy. Which statement by the nurse accurately describes the procedure? A. "The doctor will place a small needle in your back and will withdraw some fluid." B. "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." C. "You will be alone because the procedure is sterile; we cannot allow additional people to contaminate the area." D. "You will be sedated, so you will not be aware of anything."
B. "You may experience a crunching sound or a scraping sensation as the needle punctures your bone."
After reviewing the laboratory test results, the nurse calls the health care provider about which client? A. A 44-year-old receiving warfarin (Coumadin) with an international normalized ratio (INR) of 3.0 B. A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 C. A 49-year-old with hemophilia and a platelet count of 150,000/mm3 D. A 52-year-old who has had a hemorrhage with a reticulocyte count of 0.8%
B. A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 The client with a fever is neutropenic and is at risk for sepsis unless interventions such as medications to improve the WBC level and antibiotics are prescribed. The INR of 3.0 in the 44-year-old indicates a therapeutic warfarin level. A platelet count of 150,000/mm3 in the 49-year-old is normal. An elevated reticulocyte count in the 52-year-old is expected after hemorrhage.
The nurse is assisting the health care provider in performing a bone marrow aspiration. The nurse expects the health care provider to perform the procedures in what order? 1. Cleanse the site with a bactericidal agent. 2. Insert the bone marrow needle through the bone cortex. 3. Remove the stylet and attach the syringe for aspiration. 4. Infiltrate the skin and periosteum with local anesthetic.
1,4,2,3 (For bone marrow aspiration, the skin over the puncture site is cleansed with a bactericidal agent; then the skin, subcutaneous tissue, and periosteum are infiltrated with a local anesthetic agent. The bone marrow needle is inserted through the cortex of the bone. The stylet of the needle is then removed, the hub is attached to a 10-mL syringe, and 0.2 to 0.5 mL of the fluid marrow is aspirated. Text Reference - p. 630 Test-Taking Tip: In this question type, you are asked to prioritize (put in order) the options presented. For example, you might be asked the steps of performing a nursing action or skill such as those involved in medication administration.)
A patient experiences a skin allergy after contact with weeds. Which cells respond to this type of reaction? 1 Platelets 2 Basophils 3 Monocytes 4 Lymphocytes
2 (Basophils respond to allergies and stimulate antigens in response to tissue injury. Platelets aid in clot formation. Monocytes are phagocytic cells that ingest dead cells and debris. Lymphocytes respond to cellular or humoral immune responses. Text Reference - p. 616)
The thrombocytopenic patient has had a bone marrow biopsy taken from the posterior iliac crest. What nursing care is the priority for this patient after this procedure? 1 Position the patient prone 2 Apply a pressure dressing 3 Administer analgesic for pain 4 Return metal objects to the patient
2 (The sterile pressure dressing is applied after a bone marrow biopsy to ensure hemostasis. If bleeding is present, the patient will lie on the site and may need a rolled towel for additional pressure; thus, this patient will not be in the prone position. The analgesic should have been administered preprocedure. Metal objects would be removed for a magnetic resonance imaging (MRI), not a bone marrow biopsy. Text Reference - p. 630)
A nurse is reviewing a patient's laboratory reports, which show a large number of immature blast white blood cells in the blood. Which condition is likely to be found in the patient? 1 Pancytopenia 2 Neutropenia 3 Acute leukemia 4 Thrombocytopenia
3 (In acute leukemia, a complete blood count shows a large number of immature blast white blood cells present in the blood. Pancytopenia is associated with a marked decrease in the number of red blood cells, white blood cells, and platelets. Neutropenia is a condition in which the absolute neutrophil count is less than 1000 cells/μL. Thrombocytopenia is a condition in which the platelet counts falls below 100,000/μL. Text Reference - p. 625)
A patient who has undergone bone marrow aspiration is being monitored by the nurse. The nurse observes that bleeding is present at the needle aspiration site. Which action should the nurse advise the patient to perform? 1 Walking for 10 to 15 minutes 2 Sitting for 30 to 40 minutes 3 Standing for 30 to 40 minutes 4 Lying on the side for 30 to 60 minutes
4 (After bone marrow aspiration, if bleeding is present at the site, the patient should be advised to lie on the affected side for 30 to 60 minutes to maintain pressure on the site. If the bed is too soft, the patient can lie on a rolled towel to provide additional pressure. Walking, sitting, and standing do not help to maintain pressure on the site. Text Reference - p. 630)
While examining the lymph nodes during physical assessment, the nurse would be most concerned about a. a 2-cm nontender supraclavicular node. b. a 1-cm mobile and nontender axillary node. c. an inability to palpate any superficial lymph nodes. d. firm inguinal nodes in a patient with an infected foot.
A Enlarged and nontender nodes are most suggestive of malignancy such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.
While obtaining a health history from a patient with numerous petechiae on the skin, the nurse asks the patient specifically about the patient's use of a. salicylates. b. contraceptives. c. antiseizure drugs. d. antihypertensives.
A Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia, but not bleeding. Oral contraceptives increase clotting risk. Antihypertensives do not commonly cause problems with decreased clotting.
The nurse is caring for a client who has an elevated white blood cell count. Which intervention does the nurse implement for this client? a. Administer the prescribed Tylenol. b. Hold the client's prescribed steroids. c. Assess the client's respiratory rate. d. Obtain the client's temperature.
ANS: D White blood cells provide immunity and protect against invasion and infection. An elevated white blood cell count could indicate an infectious process, which could cause an elevation in body temperature. Tylenol would treat a fever but not the elevated white blood cell count. Steroids place the client at higher risk for infection but should not be stopped suddenly. The respiratory rate does not need to be assessed in this client.
Why is it important for the nurse to teach the client starting on the anticoagulant warfarin (Coumadin) to limit his or her intake of leafy green vegetables? A. These foods contain vitamin K, which can increase the effects of warfarin. B. These foods contain vitamin K, which can reduce the effects of warfarin. C. These foods enhance aspirin activity and increase the risk for bleeding in the person who also takes warfarin. D. These foods reduce aspirin activity and increase the risk for pulmonary embolism in the person who also takes warfarin.
Answer: B Rationale: Warfarin is an anticoagulant that works by reducing the amount of vitamin K available for the liver to synthesize four different essential clotting factors. Ingesting large amounts of vitamin K can counteract the effects of warfarin.
Which blood test result for a client being assessed for a hematologic problem indicates to the nurse that chronic anemia is likely? A. International normalized ratio (INR) is 0.9 B. Platelet count of 180,000/mm3 C. Reticulocyte value of 14% D. Hematocrit of 27%
Answer: C Rationale: The normal reticulocyte value is 2% or less of the total red blood cell (RBC) count. A reticulocyte is an immature RBC that still has its nucleus. An elevated reticulocyte count indicates that RBCs are being produced and released by the bone marrow before they mature. This often happens when a person has a condition that causes continual but very slow bleeding and anemia. This client has a low hematocrit and is anemic. The INR and platelet values are normal.
A patient's complete blood count shows a hemoglobin of 20 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding? a. "Has there been any recent weight loss?" b. "Do you have any history of lung disease?" c. "What is your intake of fruits and vegetables?" d. "Have you noticed any dark or bloody stools?"
B The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic lung disease. The other questions will be appropriate for patients who are anemic.
The complete blood count (CBC) and differential indicate that a patient is neutropenic. Which action should the nurse include in the plan of care? a. Avoid intramuscular injections. b. Encourage increased oral fluids. c. Check temperature every 4 hours. d. Increase intake of iron-rich foods.
C Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. The other actions would not address the patient's neutropenia.
The clinic nurse is discharging a 20-year-old client who had a bone marrow aspiration performed. What does the nurse advise the client to do? A. "Avoid contact sports or activity that may traumatize the site for 24 hours." B. "Inspect the site for bleeding every 4 to 6 hours." C. "Place an ice pack over the site to reduce the bruising." D. "Take a mild analgesic, such as two aspirin, for pain or discomfort at the site."
C. "Place an ice pack over the site to reduce the bruising." Ice to the site will help limit bruising and tissue damage during the first 24 hours after the procedure. Contact sports and traumatic activity must be excluded for 48 hours, or 2 days. The client should carefully monitor the site every 2 hours for the first 24 hours after the procedure. A mild analgesic is appropriate, but it should be aspirin-free; acetaminophen (Tylenol) would be a good choice.
A client with a low platelet count asks why platelets are important. How does the nurse answer? A. "Platelets make your blood clot." B. "Blood clotting is prevented by your platelets." C. "The clotting process begins with your platelets." D. "Your platelets finish the clotting process."
C. "The clotting process begins with your platelets."
Which client does the medical unit charge nurse assign to an LPN/LVN? A. A 23-year-old scheduled for a bone marrow biopsy with conscious sedation B. A 35-year-old with a history of a splenectomy and a temperature of 100.9° F (38.3° C) C. A 48-year-old with chronic microcytic anemia associated with alcohol use D. A 62-year-old with atrial fibrillation and an international normalized ratio of 6.6
C. A 48-year-old with chronic microcytic anemia associated with alcohol use
When evaluating the red cell indices of a patient, the nurse knows that a low mean corpuscular volume (MCV) indicates a. hypochromic red blood cells (RBCs). b. inadequate numbers of RBCs. c. low hemoglobin in the RBCs. d. small size of the RBCs
D The MCV is low when the RBCs are smaller than normal. Inadequate numbers of RBCs are an indication of anemia. Low levels of hemoglobin in the RBCs and hypochromic RBCs result in a low mean corpuscular hemoglobin (MCH).
When reviewing the complete blood count (CBC) for a patient admitted with abdominal pain, which information will be most important for the nurse to communicate to the health care provider? a. Monocytes 4% b. Hemoglobin 11.6 g/dL c. Platelet count 145,000/μL d. White blood cells (WBCs) 13,500/μL
D The elevation in WBCs indicates that an abdominal infection may be the cause of the patient's pain and that further diagnostic testing is needed. The monocytes are at a normal level. The slight decreases in hemoglobin and platelet count also would be reported but would not require any immediate action.
The health care provider orders an ultrasound of the spleen for a patient who has been in a car accident. Which action should the nurse take before this procedure? a. Check for any iodine allergy. b. Insert a large-bore IV catheter. c. Place the patient on NPO status. d. Assist the patient to a flat position.
D The patient is placed in a flat position before splenic ultrasound. The patient does not have to be NPO or have an IV line. No iodine-containing materials are used for ultrasound.
The health care provider performs a bone marrow aspiration from the left posterior iliac crest on a patient with pancytopenia. Following the procedure, the nurse should a. elevate the head of the bed to 45 degrees. b. apply a sterile Band-Aid at the aspiration site. c. use half-inch sterile gauze to pack the wound. d. have the patient lie on the left side for an hour.
D To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. The wound after bone marrow biopsy is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication that the head needs to be elevated for this patient.
When caring for a patient who is receiving heparin, the nurse will monitor a. prothrombin time (PT). b. fibrin degradation products (FDP). c. international normalized ratio (INR). d. activated partial thromboplastin time (aPTT).
D aPTT testing is used to determine whether heparin is at a therapeutic level. FDP is useful in diagnosis of problems such as disseminated intravascular coagulation (DIC). PT and INR are most commonly used to test for therapeutic levels of warfarin (Coumadin).
A client with anemia asks, "Why am I feeling tired all the time?" How does the nurse respond? A. "How many hours are you sleeping at night?" B. "You are not getting enough iron." C. "You need to rest more when you are sick." D. "Your cells are delivering less oxygen than you need."
D. "Your cells are delivering less oxygen than you need."
client is scheduled for a bone marrow aspiration. What does the nurse do before taking the client to the treatment room for the biopsy? A. Clean the biopsy site with an antiseptic or povidone-iodine (Betadine). B. Hold the client's hand and ask about concerns. C. Review the client's platelet (thrombocyte) count. D. Verify that the client has given informed consent.
D. Verify that the client has given informed consent.
A pregnant woman has Type O negative blood type. A nurse understands that the patient can have complications related to pregnancy if the fetus is Type O positive blood. How should the nurse prevent complications in the patient? 1 Obtain a prescription for antibiotics 2 Advise her to take herbal medicine 3 Instruct her to take folic acid preparation 4 Administer Rho(D) immune globulin (RhoGAM) injections
4 (In a pregnant woman with Type O negative blood type, the mother's anti-D antibodies can cross the placenta and attack the red blood cells (RBC) of a fetus that is Rh-positive. This can lead to hemolysis of the RBCs. A pregnant woman with O negative should receive Rho(D) immune globulin (RhoGAM) injections to prevent the formation of anti-D antibodies. Antibiotics and herbal medicines may not affect antibody production. Folic acid preparation can help in preventing neural tube defects, but do not affect antibody production. Text Reference - p. 627)
While reviewing the laboratory test results of a patient, the nurse finds that the patient's methylmalonic acid (MMA) level is 0.4 μmol/L and hemoglobin is 10 mg/dL. What does the nurse infer from this finding? 1 The patient has hemolytic anemia. 2 The patient has iron-deficiency anemia. 3 The patient has folic acid deficiency anemia. 4 The patient has vitamin B12-deficiency anemia.
4 (Methylmalonic acid (MMA) is an indirect test for cobalamin (vitamin B12) because MMA metabolism requires cobalamin. It helps to differentiate cobalamin deficiency from folic acid deficiency. The normal value of methylmalonic acid is less than 0.2 μmol/L. Therefore, a high methylmalonic acid level of 0.4 μmol/L indicates reduced metabolism due to a deficiency of cobalamin. Because the patient has a low hemoglobin level of 10 g/dL, the nurse infers that the patient has vitamin B12-deficiency anemia. The patient with hemolytic anemia will have high bilirubin levels and have a positive Coombs test. The patient with iron deficiency anemia will have decreased serum iron, ferritin, and an increased total iron binding capacity. The patient with folic acid deficiency anemia will have a value of folic acid less than 3 to16 ng/mL. Text Reference - p. 628)
Laboratory reports indicate that a patient has a serum iron level of 120 mcg/dL and total iron binding capacity is 300 mcg/dL. What is the transferrin saturation level of the patient? Record your answer using a whole number. _________%
40 (The patient has a serum iron level of 120 mcg/dL and total iron binding capacity is 300 mcg/dL. The formula to calculate transferrin saturation level = (serum iron level/TIBC) x 100 = (120/300) x 100 = 40%. Text Reference - p. 628)
When doing discharge teaching for a patient who has had an emergency splenectomy following an automobile accident, the nurse will teach the patient about the increased risk for a. infection. b. lymphedema. c. chronic anemia. d. prolonged bleeding.
A Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after splenectomy.
The nurse who is reviewing laboratory data for an 86-year-old patient will be most concerned about a. a white blood cell (WBC) count of 3500/uL. b. a hematocrit of 37%. c. a platelet count of 400,000/uL. d. a hemoglobin of 11.8 g/dL.
A The total WBC count is not usually affected by aging, and the low WBC here would indicate that the patient's immune function may be compromised. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.
The nurse is caring for a client who has a decreased serum iron level. Which intervention does the nurse prioritize for this client? a. Dietary consult b. Family assessment c. Cardiac assessment d. Administration of vitamin K
ANS: A Diets can alter cell quality and affect blood clotting. Diets low in iron can cause anemia and decrease the function of all red blood cells. The question does not say that the hemoglobin is low enough to affect the cardiac function. Family assessment may be important in finding out any genetic or family lifestyle causes of the low serum iron level. However, the first intervention that the nurse can provide is to have the client's dietary habits evaluated and changed so that iron levels can increase. Vitamin K is involved with clotting, not with iron stores.
The nurse is assessing a 75-year-old male client. Which blood value indicates that the client is experiencing normal changes associated with aging? a. Hemoglobin, 13.0 g/dL b. Platelet count, 100,000/mm3 c. Prothrombin time (PT), 14 seconds d. White blood cell (WBC) count, 5000/mm3
ANS: A Hemoglobin levels in men and women fall after middle age. Therefore, this client's hemoglobin value would be considered part of the aging process. Platelet counts and blood-clotting times are not age related; the client's platelet count and PT are elevated for some other reason. The WBC count shown is normal. pg 860
The nurse is assessing a client with numerous areas of bruising. Which question does the nurse ask to determine the cause of this finding? a. "Do you take aspirin?" b. "How often do you exercise?" c. "Are you a vegetarian?" d. "How often do you take Tylenol?"
ANS: A Platelet aggregation is essential for blood clotting. An inability to clot blood when an injury occurs can result in bleeding, which would cause bruising. Aspirin is a drug that interferes with platelet aggregation and has the ability to "plug" an extrinsic event, such as trauma. Vitamin K found in green vegetables enhances clotting factors, which would improve the ability to stop bleeding associated with an extrinsic event. Acetaminophen (Tylenol) and exercise do not inhibit clotting factors.
The nurse is planning discharge teaching for a client who has a splenectomy. Which statement does the nurse include in this client's teaching plan? a. "Avoid crowds and people who are sick." b. "Do not eat raw fruits or vegetables." c. "Avoid environmental allergens." d. "Do not play contact sports."
ANS: A The spleen is the major site of B-lymphocyte maturation and antibody production. Those who undergo splenectomies for any reason have a decreased antibody-mediated immune response and are particularly susceptible to viral infections. Eating raw fruits and vegetables places the client at risk for bacterial infections. The body responds to environmental allergens with an unspecific inflammatory process. The client is not at risk for bleeding or injury due to contact sports.
The nurse is assessing a client whose warfarin (Coumadin) therapy was discontinued 3 weeks ago. Which laboratory test result indicates that the client's warfarin therapy is no longer therapeutic? a. International normalized ratio (INR), 0.9 b. Reticulocyte count, 1% c. Serum ferritin level, 350 ng/mL d. Total white blood cell (WBC) count, 9000/mm3
ANS: A Warfarin therapy increases the INR. Normal INR ranges between 0.7 and 1.8. Therapeutic warfarin levels, depending on the indication of the disorder, should maintain the INR between 1.5 and 3.0. When the effects of warfarin are no longer present, the INR returns to normal levels. Warfarin therapy does not affect white blood cell count, serum ferritin level, or reticulocyte count. pg 866
The nurse is teaching a client who is receiving sodium warfarin (Coumadin). Which topics does the nurse include in the teaching plan? (Select all that apply.) a. Foods high in vitamin K b. Using acetaminophen (Tylenol) for minor pain c. Daily exercise and weight management d. Use of a safety razor and soft toothbrush e. Blood testing regimen
ANS: A, B, D, E The client on warfarin will need to know which foods are high in vitamin K because vitamin K intake must be consistent to avoid interfering with the anticoagulant properties of warfarin. Clients should not take aspirin or NSAIDs for minor pain owing to their anticoagulant properties. Clients must use safety razors and soft toothbrushes to avoid bleeding episodes. The client on warfarin needs regular blood tests for prothrombin time (PT) and international normalized ratio (INR). Daily exercise and weight management are not specifically important to this client.
The nurse is monitoring a client with liver failure. Which assessments does the nurse perform when monitoring for bleeding in this client? (Select all that apply.) a. Gums b. Lung sounds c. Urine d. Stool e. Hair
ANS: A, C, D The liver is the site for production of clotting factors. Without these factors, the client is at risk for bleeding. Common areas of bleeding include the gums and mucous membranes, bladder, and gastrointestinal tract. Lung sounds and hair are part of the assessment but are not essential in the presence of liver failure and hematologic abnormalities.
The nurse is completing the preoperative checklist on a client. The client states, "I take an aspirin every day for my heart." How does the nurse respond? a. "I will call your doctor and request a prescription for pain medication." b. "I need to call the surgeon and reschedule your surgery." c. "I'll give you the prescribed Tylenol to minimize any headache before surgery." d. "I need to administer vitamin K to prevent bleeding during the procedure."
ANS: B Aspirin and other salicylates interfere with platelet aggregation—the first step in the blood-clotting cascade—and decrease the ability of the blood to form a platelet plug. These effects last for longer than 1 week after just one dose of aspirin. The client may need to have the surgery rescheduled. Vitamin K, prescribed pain medication, and Tylenol cannot reduce the anticlotting effects of aspirin.
The nurse is teaching a client who has undergone a bone marrow biopsy. Which instruction does the nurse give the client? a. "Wear protective gear when playing contact sports." b. "Monitor the biopsy site for bruising." c. "Remain in bed for at least 12 hours." d. "Use a heating pad for pain at the biopsy site."
ANS: B The most important instruction is to have the client monitor the area for external or internal bleeding. Activities such as contact sports should be avoided, and an ice pack can be used to limit bruising.
The nurse is planning care for a client who has a platelet count of 30,000/mm3. Which intervention does the nurse include in this client's plan of care? a. Oxygen by nasal cannula b. Bleeding Precautions c. Isolation Precautions d. Vital signs every 4 hours
ANS: B The normal platelet count ranges between 150,000 and 400,000/mm3. This client is at extreme risk for bleeding. Although it is necessary to notify the provider, the nurse would first protect the client by instituting Bleeding Precautions. The other interventions are not related to the low platelet count.
The nurse helps to ambulate a client who has anemia. Which clinical manifestation indicates that the client is not tolerating the activity? a. Blood pressure of 120/90 mm Hg b. Heart rate of 110 beats/min c. Pulse oximetry reading of 95% d. Respiratory rate of 20 breaths/min
ANS: B The red blood cells contain thousands of hemoglobin molecules. The most important feature of hemoglobin is its ability to combine loosely with oxygen. A low hemoglobin level can cause decreased oxygenation to the tissues, thus causing a compensatory increase in heart rate. The other options are close to normal range and are not indicative of not tolerating this activity.
The nurse is preparing a client for a bone biopsy and aspiration. The client asks, "Will this be painful?" How does the nurse respond? a. "The procedure is always done under general anesthesia." b. "The biopsy lasts for only 2 minutes." c. "There is a chance that you may have pain." d. "You can relieve pain with guided imagery."
ANS: C Clients may have pain during this procedure. The type and amount of anesthesia or sedation depend on the physician's preference, the client's preference, and previous experience with bone marrow aspiration. The procedure takes from 5 to 15 minutes. Guided imagery can relieve pain but works well only with some clients.
The nurse is assessing a client's susceptibility to rejecting a transplanted kidney. Which result does the nurse recognize as increasing the client's chances of rejection? a. Decreased T-lymphocyte helper b. Decreased white blood cell count c. Increased cytotoxic-cytolytic T cell d. Increased neutrophil count
ANS: C Cytotoxic-cytolytic T cells function to attack and destroy non-self-cells, specifically virally infected cells and cells from transplanted grafts and organs. A high level of these cells would increase the chances of rejection. Decreased white blood cells would indicate immune suppression. Neutrophils are increased during an infection. pg 857
A female client is admitted with the medical diagnosis of anemia. The nurse assesses for which potential cause? a. Diet high in meat and fat b. Daily intake of aspirin c. Heavy menses d. Smoking history
ANS: C Iron levels can be low because intake of iron is too low, or because loss of iron through bleeding is excessive. A premenopausal woman may be having unusually heavy menses sufficient to cause excessive loss of blood and iron. Smoking and aspirin do not cause iron deficiency. A diet high in meat provides iron. pg 861
The nurse observes yellow-tinged sclera in a client with dark skin. Based on this assessment finding, what does the nurse do next? a. Assess the client's pulses. b. Examine the soles of the client's feet. c. Inspect the client's hard palate. d. Auscultate the client's lung sounds.
ANS: C Jaundice can best be observed in clients with dark skin by inspecting the oral mucosa, especially the hard palate, for yellow discoloration. Because sclera may have subconjunctival fat deposits that show a yellow hue, and because foot calluses may appear yellow, neither of these areas should be used to assess for jaundice. The client's pulse and lung sounds have no correlation with an assessment of jaundice.
The nurse is caring for a client who is receiving chemotherapy for cancer. Which intervention does the nurse implement for this client? a. Assess the client's fibrinogen level. b. Administer the prescribed iron. c. Maintain strict Standard Precautions. d. Monitor the client's pulse oximetry
ANS: C The client who is receiving chemotherapy drugs that suppress the bone marrow will be at risk for a decreased white blood cell (WBC) count and infection. The nurse will be most therapeutic by adhering to Standard Precautions to prevent infection, such as handwashing. The nurse will not expect the fibrinogen level to be affected by this therapy. Iron is not typically administered with chemotherapy because this is bone marrow suppression, so the administration of epoetin (Epogen) or filgrastim (Neupogen) is most effective. Monitoring the pulse oximetry is part of routine care and probably would not need to be done continuously.
The nurse is caring for four clients with hematologic-type problems. Which client does the nurse prioritize to see first? a. 18-year-old female with decreased protein levels b. 36-year-old male with increased lymphocytes c. 60-year-old female with decreased erythropoietin d. 82-year-old male with an increased thromboxane level
ANS: C The kidney releases more erythropoietin when tissue oxygenation levels are low. This growth factor then stimulates the bone marrow to increase red blood cell (RBC) production, which improves tissue oxygenation and prevents hypoxia. Hypoxia causes the body to increase its respiratory rate to overcome decreased oxygenation of the tissues. All these clients are important, but the woman with decreased erythropoietin takes priority because of her risk for hypoxia.
The nurse is performing an admission assessment on a 46-year-old client, who states, "I have been drinking a 12-pack of beer every day for the past 20 years." Which laboratory abnormality does the nurse correlate with this history? a. Decreased white blood cell (WBC) count b. Decreased bleeding time c. Elevated prothrombin time (PT) d. Elevated red blood cell (RBC) count
ANS: C The liver is the site for production of prothrombin and most of the blood-clotting factors. If the liver is damaged because of chronic alcoholism, it is unable to produce these clotting factors. Therefore, the PT could become elevated, which would reflect deficiency of some clotting factors. The WBC would not be elevated in this situation because no infection is present. Bleeding time would likely increase. The client's RBC count most likely would not be affected unless the client was bleeding, in which case it would decrease.
A client who has a chronic vitamin B12 deficiency is admitted to the hospital. When obtaining the client's health history, which priority question does the nurse ask this client? a. "Are you having any pain?" b. "Are you having blood in your stools?" c. "Do you notice any changes in your memory?" d. "Do you bruise easily?"
ANS: C Vitamin B12 deficiency impairs cerebral, olfactory, spinal cord, and peripheral nerve function. Severe chronic deficiency may cause permanent neurologic degeneration. The other options are not symptoms of vitamin B12 deficiency.
The nurse is assessing a client with liver failure. Which assessment is the highest priority for this client? a. Auscultation for bowel sounds b. Assessing for deep vein thrombosis c. Monitoring of blood pressure hourly d. Assessing for signs of bleeding
ANS: D All these options are important in assessment of the client, but the most important action is assessment for signs of bleeding. The liver is the site of production of prothrombin and most of the blood-clotting factors. Clients with liver failure run a high risk of having problems with bleeding.
A newly admitted client has an elevated reticulocyte count. Which disorder does the nurse suspect in this client? A. Aplastic anemia B. Hemolytic anemia C. Infectious process D. Leukemia
B. 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. Aplastic anemia is associated with a low reticulocyte count. A high white blood cell count is expected in clients with infection. A low white blood cell count is expected in clients with leukemia.
The nurse is assessing an adult client's endurance in performing activities of daily living (ADLs). What question does the nurse ask the client? A. "Can you prepare your own meals?" B. "Has your weight changed by 5 pounds or more this year?" C. "How is your energy level compared with last year?" D. "What medications do you take daily, weekly, and monthly?"
C. "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.
A client on anticoagulant therapy is being discharged. Which statement indicates that the client has a correct understanding of this therapy's purpose or action? A. "It is to dissolve blood clots." B. "It might cause me to get injured more often." C. "It should prevent my blood from clotting." D "It will thin my blood."
C. "It should prevent my blood from clotting."
