MS Week 6 Clotting Practice(Exam 5)

Notify the physician.

A client is being treated in the hospital for hypovolemia related to a bleeding peptic ulcer. The nurse obtains a blood pressure reading of 88/62 mm Hg, heart rate of 112 beats/minute, and a respiratory rate of 24 breaths/minute. What is the first action by the nurse?

T lymphocytes

Undifferentiated cells that migrate to the thymus gland develop into which of the following?

Heart rate of 120 beats/minute

When obtaining vital signs from a client who has reduced erythrocyte production and a hemoglobin level of 8.2 g/dL, what results would be indicative of these lab studies?

A 55-year-old client with an immunosuppression disorder

Which client does the nurse recognize as most likely to be diagnosed with non- Hodgkin's lymphoma rather than Hodgkin's lymphoma?

An INR of 4.8

Which nursing observation would indicate that the nurse hold the medication warfarin (Coumadin)?

Compromised nutrition interferes with production of blood cells and hemoglobin.

Why would it be important for the nurse to obtain information regarding dietary history of a client with a possible abnormality of the hematopoietic or lymphatic system?

Involved in the transfer of iron from storage to plasma

A client has laboratory studies that determine he is deficient in copper. What does the nurse understand is the importance of copper in the body?

5.0 g/dL

A client is brought to the emergency department with suspected bleeding esophageal varices. Which hemoglobin level should the nurse immediately report to the physician?

Reed-Sternberg cells

A client is having a lymph node biopsy for suspicion of Hodgkin's disease. What type of cells would be identifiable in the lymph node biopsy that may indicate this disease process?

Vascular occlusion in small vessels decreasing blood and oxygen to the tissues

A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client?

Helps retain fluid in the vascular compartment

Albumin is a protein in the plasma portion of the blood. Under normal conditions, albumin cannot pass through the wall of a capillary. What significance does this have for the vascular compartment?

"One episode produces immunity, but the virus remains for a lifetime."

An adolescent client diagnosed with infectious mononucleosis asks the nurse if he will keep getting the disease. What is the best response by the nurse?

Elevate the affected part of the body.

An adult client has developed lymphedema postmastectomy. What is the common method used to promote lymphatic drainage and prevent edema in all clients with lymphedema?

In the lymph node

Macrophages attack and destroy foreign substances to the body. Where does this action occur?

"The child must inherit two defective genes, one from each parent."

Parents arrive to the clinic with their young child and inform the nurse the child has just been diagnosed with sickle cell disease. The parents ask the nurse how this could have happened and which one of them is the carrier. What is the best response by the nurse?

Give oxygen per nasal cannula

The LPN is following a plan of care for a client who is being treated for hypovolemic anemia and is at risk for hypovolemic shock. The nurse assesses vital signs and O2 saturation and observes the saturation at 89% for 3 minutes. What should the first action by the nurse be?

Offer clear liquids such as carbonated beverages, water, and ice pops.

The client is receiving chemotherapy for a diagnosis of lymphosarcoma. The client experiences nausea. What measures should the nurse suggest to help the client reduce the feeling of nausea?

reduced urine output

The client was admitted to the emergency department after an accident with a chain saw. The client is exhibiting signs and symptoms of acute hypovolemic anemia from severe blood loss. What signs and symptoms would the nurse assess for?

safety

The nurse is assisting the client with multiple myeloma to ambulate. What is the most important nursing diagnosis to help prevent fractures in this client?

polycythemia

The nurse would anticipate that which of the following patient conditions will be treated with the collaborative treatment of regular phlebotomies?

Coagulopathies are bleeding disorders that involve platelets or clotting factors.

The nursing instructor is talking with her clinical group about coagulopathies. How should the instructor define coagulopathies?

Transportation of O2 to the tissues and removal of CO2 from the tissues

The nursing instructor is teaching her clinical group about laboratory blood tests. What is the major function of erythrocytes?

An older adult client on a fixed income. A client with Crohn's disease. A young female client with bulimia nervosa

The registered nurse (RN) and licensed practical nurse (LPN) are preparing an educational program for clients who may be at risk for the development of iron-deficiency anemia. Which clients would receive the greatest benefit from this program? Select all that apply. A. An older adult client on a fixed income B. A client with Crohn's disease C. A client who lives in a nursing home D. A client who is a vegetarian E. A young female client with bulimia nervosa

30 to 50 days

A client calls the clinic and informs the nurse that her boyfriend was diagnosed with infectious mononucleosis and wonders how long it would be before she got it. What does the nurse inform the client that the incubation period is for infectious mononucleosis?

Inspect and measure the arm.

A client comes to the clinic and informs the nurse of swelling in right arm. There has been no injury or precipitating occurrence that caused the swelling. The nurse observes nonpitting edema from the upper arm to the fingertips. What action should the nurse initially perform?

A streptococcal microorganism

A client has developed an infection that resulted in lymphangitis. What does the nurse suspect the causative organism is that caused the infection?

postural hypotension

A client is experiencing chronic hypovolemic anemia as evidenced by laboratory results. What symptoms does the nurse expect to find for this client when collecting objective data?

Destruction of normally formed red blood cells Blood loss Abnormal erythrocyte production

A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply. A. infection B. destruction of normally formed red blood cells C. inadequate formed white blood cells D. blood loss E. abnormal erythrocyte production

B

A client with Hodgkin's disease has a weight loss of 10% of body weight 6 months prior to the diagnosis, fever of 101°F, and drenching night sweats. What subclassification of Hodgkin's disease does this client fit into?

IV

A client with Hodgkin's disease has bilateral lymph nodes that are affected with extension through the spleen as well as affecting the bone marrow. What stage of the disease does the nurse recognize the client is in?

Neurologic involvement

A client with a diagnosis of pernicious anemia comes to the clinic complaining of numbness and tingling in his arms and legs. What do these symptoms indicate?

How to apply an elastic sleeve or stocking

A client with lymphadenitis has developed persistent swelling of the affected area. What would be important information for the nurse to teach this client?

lymphangiography

A client with lymphedema in the left arm has weeping from the skin and has a small 2- cm ulcer on the upper arm. What test does the nurse anticipate the client will be prepared for?

The manufacture and development of blood cells

A client's family member asks what hematopoiesis is. What should the nurse tell the family member?

Gamma globulins

A nurse is providing care to a cancer client. Which protein in plasma functions primarily as immunologic agents?

Use a soft bristle toothbrush

A patient on a medical surgical unit has a platelet count of 90,000 per mm3. The nurse knows to include which of the following precautions in discharge instructions?

dependent position

A patient states that his legs have pain with walking that decreases with rest. The nurse observes absence of hair on the patient's lower leg and the patient has a thready posterior tibial pulse. How would the nurse position the patient's legs?

Immunologic agents

A student nurse is having difficulty understanding the function of globulins. What information can the client provide to the student regarding the function of globulins?

Fresh frozen plasma

A teenaged client with hemophilia sustains a leg laceration after falling off of his skateboard and is brought to the emergency department. The laceration is bleeding profusely even with direct pressure to the site. What does the nurse anticipate will be ordered for administration to control bleeding?

It is a group of cancers that affect the lymphatic system

A young client has just been diagnosed with lymphoma. The client asks the nurse what a lymphoma is. What would be the nurse's best answer?

Trauma and microabrasions from a nonelectric razor may contribute to anemia.

The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. What is the rationale for this statement by the nurse?

Bronzing of the skin

The nurse is admitting a client with Cooley's anemia to the hospital with a hemoglobin of 6.2 g/dL and hematocrit of 26%. What does the nurse document about the client's skin?

"It helps adequately hydrate you and ensures a sufficient urine production."

The nurse is assigned to care for a client with polycythemia vera. When the nurse encourages the client to drink 3 L of fluid per day, the client states, "Why do I have to drink so much?" What is the best response by the nurse?

A fibrin sponge

The nurse is assisting the physician to control the bleeding for a client who has had an insertion of a vascular access. What can the nurse obtain for the physician to use to control the bleeding?

A bone marrow aspiration

The nurse is assisting the physician with obtaining a sample to determine the status of blood cell formation. What type of procedure will the nurse have prepared the client for?

transfusions

The nurse is caring for a client with Hodgkin's disease who has developed anemia. What would the nurse expect to be ordered for this client?

Complaints of a sense of fullness in the stomach and epigastric pain

The nurse is caring for a client with a diagnosis of Hodgkin's disease and is aware that there is enlargement of the retroperitoneal nodes when reviewing the review of systems on the physician's history and physical. What symptom is the nurse aware may be indicative of enlargement of the retroperitoneal nodes?

Client A has a higher WBC count than normal, client B has a normal hemoglobin count, and client C has a normal platelet count.

The nurse is caring for three clients who have the following blood count values: Client A has 24,500/mm3 white blood cells (WBCs), client B has 13.4 g/dL hemoglobin, and client C has a 250,000/mm3 platelet count. Which statement correctly describes the condition of each client?

"I have difficulty breathing when walking 30 feet."

The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?

GradeIII(Severe)

The nurse is collecting objective data from the client with lymphedema of the left leg. The nurse observes that the affected leg is 10 cm greater in measurement than the unaffected leg. The affected leg is hot to the touch and red. What classification of lymphedema does the nurse recognize this client has?

vitamin C

The nurse is discussing vitamin replacement with a client in the clinic. Which vitamin should the nurse discuss with the client in order to increase the absorption of folic acid and iron?

Dilute the liquid preparation with another liquid such as juice and drink with a straw.

The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions?

thrombocytopenia

The nurse is observing the skin of a client who is taking medications that depress the hematopoietic system and notices multiple areas of ecchymosis on the arms; bleeding for a prolonged period after an IV was started; and reports of black, tarry stool. What does the nurse understand may be a side effect of this medication that the client displays?

Red streaks following the course of the lymph channels

The nurse is obtaining objective data from a client with lymphangitis of the left arm. What does the nurse expect to find when collecting this data from the client?

?????

The nurse is on a mission trip to a third world country to provide nursing care to a large group of clients. A client asks the nurse to look at his leg that is grossly edematous compared to the other extremity. What does the nurse understand is the most common cause of this disorder known as elephantiasis?

Helps muscles to propel lymphatic drainage Increases local tissue pressure Prevents tissue refilling with an excess volume of lymph Decreases the stretching of the skin

The nurse is sending a client to be fitted for a compression garment for the treatment of lymphedema after having a mastectomy and node dissection. What does the nurse inform the client that will do to decrease the edema? Select all that apply. A. Helps muscles to propel lymphatic drainage B. If worn for 30 days continuously, will permanently reduce the edema C. Increases local tissue pressure D. Prevents tissue refilling with an excess volume of lymph E. Decreases the stretching of the skin

platelets

The nurse observes that a client who had an arterial blood gas performed 30 minutes ago is still oozing blood from the puncture site. Pressure was held to the site for 5 minutes after the puncture and another 5 minutes when the site was still oozing. What factor does the nurse know will participate in the ability for the blood to clot?

Erythrocytes that are microcytic and hypochromic

The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia?

Over the posterior superior iliac crest

The nurse will be assisting the physician with a bone marrow aspiration. Where should the nurse cleanse, clip hair, and drape the skin before the procedure?

hip replacement

The nurse would expect to administer an anticoagulant to a patient following which surgery?

polycythemia vera

The nursing instructor is discussing disorders of the hematopoietic system with the pre- nursing pathophysiology class. What disease would the instructor list with a primary characteristic of erythrocytosis?

Erythrocyte count

A client is seeing the physician at the clinic and tells the nurse he is fatigued and short of breath with minimal exertion. What lab study may reflect a decrease in transport of oxygen?

Fever, sore throat, and chills

A client is taking a medication that has the side effect of depressing the hematopoietic system. What signs of leukopenia should the nurse monitor for while the client is taking this drug?

nitric oxide

The nurse is instructing the client with sickle cell disease about the use of an inhaled vasodilator that may reduce sickling. What medication is the nurse instructing the client about?

"I will increase the intake of green, leafy vegetables for a more healthful diet."

statement

aplastic anemia

A client comes to the walk-in clinic complaining of weakness and fatigue. While assessing this client, the nurse finds evidence of petechiae and ecchymoses. The nurse notes that the spleen appears enlarged. What would the nurse suspect is wrong with this client?

congestive heart failure

A client diagnosed with polycythemia vera has come into the clinic because he has developed a nighttime cough, fatigue, and shortness of breath. From these clinical manifestations, what complication would the nurse suspect in this client?

An accumulation of lymphatic fluid that results from impaired lymph circulation

A client had a left radical mastectomy with an axillary node dissection 6 months ago and is having a large amount of edema in the left arm down to the fingers. What should the nurse inform the client is the reason for the edema?

Are you experiencing fever, chills, or night sweats?

A client has just been admitted to the unit with a diagnosis of Hodgkin's disease. When doing the initial assessment, what pertinent questions should the nurse ask the client to help determine the correct nursing diagnosis?

Elevated eosinophils

A client informs the nurse that he is having a difficult time coping with seasonal allergies and have taken some over-the-counter medications to assist with control of symptoms. What results would indicate to the nurse that the client does have allergies?

O Rh-positive or O Rh-negative

A client is admitted to the emergency department with significant blood loss. The physician orders 2 units of packed red blood cells to be transfused immediately. Which blood groups would be compatible with his O Rh-positive blood group?

Iron

A client is being treated for anemia and has a hemoglobin level of 9.6 g/dL. What does the nurse understand is the basic nutritional component of heme in hemoglobin that the client may be deficient in?

Secondary edema of the left calf

A client is in the burn unit following a motor vehicle accident. The nurse notes nonpitting edema in the client's left calf. What would the nurse document about this finding?

Monospot test

A teenaged client arrives at the clinic and informs the nurse that he attended 2 weeks of summer camp last month and now is not feeling well with complaints of sore throat, fever, and very tired. The nurse observes white exudate on the tonsils. What test does the nurse anticipate the physician will order for this client?

Eat soft, bland foods and drink cool liquids.

The nurse is caring for a client diagnosed with infectious mononucleosis who is having trouble eating. What would the nurse advise this client to improve his oral intake?

Doxorubicin, bleomycin, vinblastine, dacarbarine

The nurse is caring for a client in the hospital who is being treated for Hodgkin's disease and is taking a chemotherapeutic regimen in the hospital's oncology unit. When reviewing the client's medication history, what regimen does the nurse recognize as the drugs in the treatment of Hodgkin's disease?

Elevate the area.Apply warm soaks/compresses to the area. Encourage independent activities of daily living. Apply ice to the area. Note the response to antibiotic therapy.

The nurse is caring for a client newly admitted to the unit with a diagnosis of lymphangitis. What interventions would the nurse institute to help promote the resolution of the lymphangitis? Select all that apply. A. Elevate the area.Apply warm soaks/compresses to the area. B. Encourage independent activities of daily living. C. Apply ice to the area D. Note the response to antibiotic therapy.

Support the client and monitor the status

The nurse is caring for a client who is undergoing bone marrow aspiration to determine the blood cell formation status. What nursing intervention should the nurse provide to the client during the test?

Urine output of 15 mL/hr

The nurse is caring for a client with hypovolemic anemia who is now in hypovolemic shock. What indication does the nurse have that the client is having inadequate renal perfusion?

Notify the physician

The nurse is caring for a client with lymphangitis of the right leg who is receiving treatment with a broad-spectrum antibiotic. The nurse is giving a bath and observes the right leg is larger than it was 2 hours ago and the client feels hot. What is the first action by the nurse?

GradeII(Moderate)

The nurse is caring for a client with lymphedema of the left arm in the clinic. The nurse measures a circumference of the affected extremity 4 cm larger in circumference than the opposite limb, and the client complains of feeling a heaviness and pain. There is limited movement of the left arm. What would the nurse grade and document this lymphedema as?

Osteoclasts break down bone cells so pathologic fractures occur.

The nurse is caring for a client with multiple myeloma. Why would it be important to assess this client for fractures?

indolent

A client has been diagnosed with non-Hodgkin's lymphoma but has no symptoms at this time. The client has received radiation and chemotherapy with responsiveness to this treatment. How would this disease be classified according to the lack of symptoms and responsiveness to treatment?

The spleen is a lymphatic structure and assists with phagocytosis.

A client has been involved in an automobile accident and is assessed to have an enlarged spleen. What does the nurse understand is the significance of attempting to prevent unnecessary removal of the spleen for this client?

Assist the client with focused imagery to avoid focusing on the procedure and any discomfort associated with it.

A client is scheduled for a bone marrow aspiration and is extremely apprehensive about having the procedure done. The nurse explains that there may be a feeling of pressure or discomfort when puncturing the bone. What intervention can the nurse provide to assist with this concern?

multiple myeloma

A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms?

The nurse assists the physician and supports the client during the procedure.

A client will be having a bone marrow aspiration to determine the status of blood cell formation. What role does the nurse have during the test?

frequent infections fatigue from anemia easy bruising

A client is suspected of having leukemia and is having a series of laboratory and diagnostic studies performed. What does the nurse recognize as the hallmark signs of leukemia? Select all that apply. A. frequent infections B. fatigue from anemia C. diarrhea D. easy bruising E. nausea and vomiting

Epoetin alfa

A client with end-stage renal disease has a decreased red blood cell production. What medication can the nurse administer with physician's order that will increase the production of erythrocytes?

Suggest certain styles of clothing that conceal the enlargement of the leg.

A client with lymphedema of the left leg has a nursing diagnosis of Disturbed Body Image related to lymphedema of the left leg as evidenced by the statement, "I look terrible and am embarrassed to go out." What intervention can the nurse provide to help this client?

Obtain the pain medication and delay the bath and position change until the medication reaches its peak.

A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?

popsicle

A client with non-Hodgkin's lymphoma is receiving chemotherapy for treatment. The client is complaining of nausea during treatment. To maintain fluid intake, what type of food or fluid could the nurse offer the client?

Acute chest syndrome

A client with sickle cell disease informs the nurse that he is having chest pain. The nurse hears the client coughing, wheezing, and breathing rapidly. What does the nurse suspect is occurring with this client?

TypeO

A client is in the hospital with a bleeding gastric ulcer and requires a blood transfusion. He has been typed and cross-matched for 2 units of packed red blood cells and found to have type O blood. What type of blood will the nurse administer to this client?

Pernicious anemia Malabsorption syndromes Sickle-cell anemia

A client is scheduled for a Schilling test in the morning. What diagnostic results would be indicated if the test is positive? Select all that apply. A. Pernicious anemia B. Iron-deficiency anemia C. Malabsorption syndromes D. Agastriculcer E. Sickle-cell anemia

Place the client in a modified Trendelenburg position.

The nurse is caring for a client who is developing hypovolemic shock from a duodenal ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow to the brain?

A 19-year-old college student with cervical node enlargement and fever

The nurse is caring for a group of clients. Which client does the nurse suspect is most likely to have mononucleosis?

Observe stools for blood.

The nurse is caring for an older adult client who has hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine where the blood loss is coming from, what intervention can the nurse provide?

A 19-year-old African American male

The nurse is caring for four clients on the medical-surgical unit of the hospital. What client is mostly likely to be receiving treatment for sickle cell crisis?

vanilla pudding and iced tea

The nurse is caring for the client with infectious mononucleosis that has inflammation of the pharyngeal mucosa. What foods or liquids would be best to offer to this client?

tonsillitis

The nurse is inspecting the tonsils for a client with a fever and sore throat. The nurse observes purulent exudate on the surface of the tonsils. What does this finding indicate to the nurse?

3

The nurse is inspecting the tonsils of a client that complaints of a sore throat for size and appearance. What is the appropriate documentation for an observation of tonsils that touch the uvula?

Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.

The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise?

Blood loss from the gastrointestinal or genitourinary tract

The nurse is caring for an older adult client who has been admitted to the unit with anemia. What would the nurse expect the client to possibly exhibit?

New ecchymosis on the abdomen A nosebleed that does not stop with pressure Pallor Sudden onset of severe headache Extreme fatigue

The nurse is making a home visit to a patient who was discharged from the hospital on Lovenox and warfarin following replacement of the patient's pacemaker. Which observation indicates excessive bleeding? (Select all that apply.) A. New ecchymosis on the abdomen B. A nosebleed that does not stop with pressure C. Pallor D. Pain of the lower extremity with flexion E. Sudden onset of severe headache F. Extreme fatigue

Enlargement of the lymph glands

The nurse is performing a physical assessment on a client with a suspected lymphatic disorder. What would be the nurse's primary assessment for all clients with lymphatic disorders?

On the side opposite the aspiration site

The nurse is preparing the client for a bone marrow aspiration at the posterior iliac crest. What would be the best position for the nurse to place the client in for the test?

Limit the time the garment is not worn to 30 to 60 minutes. Purchase two compression garments. Change the garment in the morning and in the evening.

The nurse is providing instruction on the use of compression garments for the client with lymphedema. What should be included in the instructions? Select all that apply. A. Limit the time the garment is not worn to 30 to 60 minutes. B. Purchase two compression garments. C. Place the garment in the dryer after washing. D. Change the garment in the morning and in the evening. E. Replace a compression garment every month.