Chapter 39 - Assessment of the Hematological System
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? a. "Inspect the site for bleeding every 4 to 6 hours." b. "Place an ice pack over the site to reduce the bruising." c. "Avoid contact sports or activity that may traumatize the site for 24 hours." d. "Take a mild analgesic, such as two aspirin, for pain or discomfort at the site."
B
A client is scheduled for a bone marrow aspiration. What is the priority nursing action before this procedure is performed? a. Hold the client's hand and ask about concerns. b. Review the client's platelet (thrombocyte) count. c. Verify that the client has given informed consent. d. Clean the biopsy site with an antiseptic or povidone-iodine (Betadine).
C
A client on anticoagulant therapy is being discharged. Which statement by the client indicates an understanding of the anticoagulants drug action? a. "It will thin my blood." b. "It is used to dissolve blood clots." c. "It should prevent my blood from clotting." d. "It might cause me to get injured more often."
C
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? a. Hemoglobin level b. Red blood cell (RBC) count c. Platelet (thrombocyte) count d. White blood cell (WBC) response
C
Which task does the nurse delegate to unlicensed assistive personnel (UAP)? a. Refer a client with a daily alcohol consumption of 12 beers for counseling b. Obtain a partial thromboplastin time from a saline lock on a client with a pulmonary embolism c. Report any bleeding noted when catheter care is given to a client with a history of hemophilia d. Perform a capillary fragility test to check vascular hemostatic function on a client with liver failure
C
A client with a low platelet count asks the nurse, "Why are platelets important?" Which statement is the nurse's best response? a. "Platelets will make your blood clot." b. "Your platelets finish the clotting process." c. "Blood clotting is prevented by your platelets." d. "The clotting process begins with your platelets."
D
A client with anemia asks the nurse, "Why am I feeling tired all the time?" What is the nurse's best response? a. "You are not getting enough iron." b. "When you are sick you need to rest more." c. "How many hours are you sleeping at night?" d. "Your cells are delivering less oxygen than you need."
D
A client has a bone marrow biopsy performed. What is the priority postprocedure nursing action? a. Inspect the site for ecchymosis b. Apply pressure to the biopsy site c. Send the biopsy specimens to the laboratory d. Teach the client to avoid vigorous activity
B
The nurse is assessing an adult client's endurance in performing activities of daily living (ADLs). What question would the nurse ask the client? a. "Can you prepare your own meals every day?" b. "How is your energy level compared with last year?" c. "Has your weight changed by 5 pounds (2.3 kg) or more this year?" d. "What medications do you take daily, weekly, and monthly?"
B
A newly admitted client has an elevated reticulocyte count. Which condition does the nurse suspect in this client? a. Leukemia b. Aplastic anemia c. Hemolytic anemia d. Infectious process
C
The nurse is assessing the nutritional status of a client with anemia. How does the nurse obtain information about the client's diet? a. Uses a prepared list and finds out the client's food preferences b. Asks the client to rate his or her diet on a scale of 1 (poor) to 10 (excellent) c. Has the client write down everything he or she has eaten for the past week d. Determines who prepares the client's meals and plans an interview with him or her
C
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 will be sedated during the procedure, so you will not be aware of anything." c. "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." d. "You will be alone because the procedure is sterile; we cannot allow additional people to contaminate the area."
C
Which client does the medical unit charge nurse assign to a licensed practical nurse (LPN)/licensed vocational nurse (LVN)? a. A client with chronic microcytic anemia associated with alcohol use b. A client scheduled for a bone marrow biopsy with conscious sedation c. A client with a history of a splenectomy and a temperature of 100.9°F (38.3°C) d. A client with atrial fibrillation and an international normalized ratio of 6.6
A
The nurse is starting the shift by making rounds. Which client would the nurse assess first? a. A 52-year-old who just had a bone marrow aspiration and is requesting pain medication b. A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism c. A 47-year-old who had a Rumpel-Leede test and asks the nurse to "look at the bruises on my arm" d. A 42-year-old with a diagnosis of anemia who reports shortness of breath when ambulating down the hallway
B
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? a. "Yes, they do." b. "No, they don't." c. "The number varies with gender, age, and general health." d. "You have fewer red blood cells because you have anemia."
C
After reviewing the laboratory test results, the nurse calls the primary care provider about which client? a. A 52-year-old who had a hemorrhage with a reticulocyte count of 0.8% b. A 49-year-old with hemophilia and a platelet count of 150,000/mm3 (150 × 109/L) c. A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 (1.5 × 109/L) d. A 44-year-old prescribed warfarin (Coumadin) with an international normalized ratio (INR) of 3.0
C
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? a. "Where do you work?" b. "Tell me what you eat in a day." c. "Does anyone in your family bleed a lot?" d. "Do you seem to have excessive bleeding or bruising?"
C
The nurse is caring for a group of hospitalized clients. Which client is at highest risk for infection and sepsis? a. A client with hemolytic anemia b. A client with cirrhosis of the liver c. A client who had an emergency splenectomy d. A client with recently diagnosed sickle cell anemia
C
Which task does the nurse delegate to unlicensed assistive personnel (UAP) who is assisting with the care of a female client with anemia? a. Monitor the oral mucosa for pallor, bleeding, or ulceration b. Ask about the amount of blood loss with each menstrual period c. Check for sternal tenderness while applying fingertip pressure d. Count the respiratory rate before and after ambulating 20 feet (6 m)
D
