CH 41
A client has a bone marrow biopsy done. Which nursing intervention is the priority postprocedure? Applying pressure to the biopsy site Inspecting the site for ecchymoses Sending the biopsy specimens to the laboratory Teaching the client about avoiding vigorous activity
A The initial action should be to stop bleeding by applying pressure to the site.
A 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? "Avoid contact sports or activity that may traumatize the site for 24 hours." "Inspect the site for bleeding every 4 to 6 hours." "Place an ice pack over the site to reduce the bruising." "Take a mild analgesic, such as 2 aspirin, for pain or discomfort at the site."
C. Ice to the site will help limit bruising and tissue damage during the first 24 hours postprocedure.
A client with a low platelet count asks why platelets are important. How does the nurse answer? "Platelets make blood clots for you." "Blood clotting is prevented by your platelets." "The clotting process begins with your platelets." "Your platelets finish the clotting process."
C. Platelets begin the blood clotting process by forming platelet plugs, but these platelet plugs are not clots and cannot provide complete hemostasis.
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? "It is to dissolve blood clots." "It might cause me to get injured more often." "It should prevent my blood from clotting." "It will thin my blood."
C. 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.
Which action does the RN delegate to unlicensed assistive personnel (UAP)? Drawing a partial thromboplastin time (PTT) from a saline lock on a client with a pulmonary embolism Performing a capillary fragility test to check vascular hemostatic function on a client with liver failure Referring for counseling a client with a daily alcohol consumption of 12 beers a day Reporting any bleeding noted when catheter care is given to a client with a history of hemophilia
D. Reporting findings during routine care is expected and required of unlicensed staff members.
A nurse is starting the shift by making rounds. Which client does the nurse decide to assess first? 42-year-old with anemia who is reporting shortness of breath when ambulating down the hallway 47-year-old who recently had a Rumpel-Leede test and is requesting a nurse to "look at the bruises on my arm" 52-year-old who has just had a bone marrow aspiration and is requesting pain medication 59-year old who has a nosebleed and is receiving heparin to treat a pulmonary embolism
D. This client may be experiencing the bleeding as a result of excessive anticoagulation and should be assessed for the severity of the situation before the other clients, whose conditions are stable, are assessed.
A client with anemia asks, "Why am I feeling tired all the time?" How does the nurse respond? "How many hours are you sleeping at night?" "You are not getting enough iron." "You need to rest more when you are sick." "Your cells are delivering less oxygen than you need."
D. The single most common symptom of anemia is fatigue. This problem occurs because oxygen delivery to cells is less than is required to meet normal oxygen needs.
A nurse is caring for a group of hospitalized clients. Which client is at greatest risk for infection and sepsis? 18-year-old who had an emergency splenectomy 22-year-old with recently diagnosed sickle cell anemia 38-year-old with hemolytic anemia 40-year-old alcoholic with liver disease
A. Removal of the spleen causes the client to have reduced immune function. Without a spleen, people are less able to remove disease-causing organisms.
A newly admitted client has an elevated reticulocyte count. Which disorder does the nurse suspect in this client? Aplastic anemia Hemolytic anemia Infectious process Leukemia
B. An elevated reticulocyte count in the 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 red blood cells. Therefore more immature RBCs are in circulation.
After reviewing the laboratory test results, the nurse calls the health care provider about which client? 44-year-old receiving warfarin (Coumadin) with an international normalized ratio (INR) of 3.0 46-year-old with a fever and a white blood cell (WBC) count of 500/µl 49-year-old with hemophilia and a platelet count of 150,000/mm3 52-year-old who has had a hemorrhage with a reticulocyte count of 0.8%
B. This client is neutropenic and is at risk for sepsis unless interventions such as medications to improve WBC level and antibiotics are prescribed.
A nurse is assessing a client for hematologic function risks. The nurse 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? "Do you seem to have excessive bleeding or bruising?" "Does anyone in your family bleed a lot?" "Tell me what you eat in a day." "Where do you work?"
B. An accurate family history is important because many disorders that affect blood and blood clotting are inherited. Genetics cannot be changed.
A 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? Hemoglobin (Hgb) level Platelet (thrombocyte) count Red blood cell (RBC) count White blood cell (WBC) response
B. Platelet counts do not generally change with age.
A 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 may experience a crunching sound or a scraping sensation as the needle punctures your bone." "You will be alone because the procedure is a sterile one; we cannot allow additional people to contaminate the area." "You will be sedated, so you will not be aware of anything."
B. This description is accurate. Proper expectations minimize the client's fear during the procedure.
A client with anemia asks the nurse, "Do most people have the same number of red blood cells?" How does the nurse respond? "No, they don't." "The number varies with gender, age, and general health." "Yes, they do." "You have fewer red blood cells because you have anemia."'
B. This is the most educational and reasonable response to the client's question.
Which nursing action does the RN delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a female client with anemia? Asking the client about the amount of blood loss with each menstrual period Checking for sternal tenderness while applying fingertip pressure Determining the respiratory rate before and after the client walks 20 feet Monitoring her oral mucosa for pallor, bleeding, or ulceration
C. Assessment of respiratory rate before and after ambulation is within the scope of practice for UAP. UAP will report this information to the RN.
Which client does the medical unit charge nurse assign to an LPN/LVN? 23-year-old scheduled for a bone marrow biopsy with conscious sedation 35-year-old with a history of a splenectomy and a temperature of 100.9° F (38.3° C) 48-year-old with chronic microcytic anemia associated with alcohol use 62-year-old man with atrial fibrillation and an international normalized ratio (INR) of 6.6
C. This client has a chronic condition that is not considered life threatening.
A nurse is assessing an adult client's endurance in performing ADLs. What question does the nurse ask the client? "Can you prepare your own meals?" "Has your weight changed by 5 pounds or more this year?" "How is your energy level-compared with last year?" "What medications do you take daily, weekly, monthly?"
C. This question from Gordon's Functional Health Pattern Assessment 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 with ADLs.
A nurse is assessing the nutritional status of a client with anemia. How does the nurse obtain information about the client's diet? Asks the client to rate his or her diet on a scale of 1 (poor) to 10 (excellent) Determines who prepares the client's meals and plans an interview with him or her From a prepared list, finds out the client's food preferences Has the client write down everything he or she has eaten for the past week
D. This method 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 about the client's protein, vitamin, and mineral intake.
A client is scheduled for a bone marrow aspiration. What does the client's nurse do before taking the client to the treatment room for the biopsy? Cleans the biopsy site with an antiseptic or povidone-iodine (Betadine) Holds the client's hand and asks about concerns Reviews the client's platelet (thrombocyte) count Verifies that the client has given informed consent
D. Verifying informed consent must be done before the procedure can be performed. A signed permit must be on the client's chart.