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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? "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?"
"Does anyone in your family bleed a lot?" An accurate family history is important because many disorders that affect blood and blood clotting are inherited; genetics cannot be changed.
The nurse is assessing an adult client's endurance in performing activities of daily living (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, and monthly?"
"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.
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."
"It should prevent my blood from clotting." 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.
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? "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 two aspirin, for pain or discomfort at the site."
"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.
A client with a low platelet count asks why platelets are important. How does the nurse answer? "Platelets make your blood clot." "Blood clotting is prevented by your platelets." "The clotting process begins with your platelets." "Your platelets finish the clotting process."
"The clotting process begins with your platelets." Platelets begin the blood clotting process by forming platelet plugs, but these platelet plugs are not clots and cannot provide complete hemostasis. Platelets do not clot blood; they are a part of the clotting process or cascade of coagulation. Platelets do not prevent the blood from clotting; rather they function to help blood form clots. Platelets do not finish the clotting process, they begin it.
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."
"The number varies with gender, age, and general health." Telling the client that the number of red blood cells (RBCs) varies with gender, age, and general health is the most educational and reasonable response to the client's question
The 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 sterile; we cannot allow additional people to contaminate the area." "You will be sedated, so you will not be aware of anything."
"You may experience a crunching sound or a scraping sensation as the needle punctures your bone." It is accurate to describe a crunching sound or scraping sensation. Proper expectations minimize the client's fear during the procedure. A very large-bore needle is used for a bone marrow biopsy, not a small needle; the puncture is made in the hip or in the sternum, not the back.
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."
"Your cells are delivering less oxygen than you need." The single most common symptom of anemia is fatigue, which occurs because oxygen delivery to cells is less than is required to meet normal oxygen needs.
After reviewing the laboratory test results, the nurse calls the health care provider about which client? A 44-year-old receiving warfarin (Coumadin) with an international normalized ratio (INR) of 3.0 A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 A 49-year-old with hemophilia and a platelet count of 150,000/mm3 A 52-year-old who has had a hemorrhage with a reticulocyte count of 0.8%
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.
Which client does the medical unit charge nurse assign to an LPN/LVN? A 23-year-old scheduled for a bone marrow biopsy with conscious sedation A 35-year-old with a history of a splenectomy and a temperature of 100.9° F (38.3° C) A 48-year-old with chronic microcytic anemia associated with alcohol use A 62-year-old with atrial fibrillation and an international normalized ratio of 6.6
A 48-year-old with chronic microcytic anemia associated with alcohol use Chronic microcytic anemia is not considered life-threatening and can be assigned to an LPN/LVN.
The nurse is starting the shift by making rounds. Which client does the nurse decide to assess first? A 42-year-old with anemia who is reporting shortness of breath when ambulating down the hallway A 47-year-old who recently had a Rumpel-Leede test and is requesting a nurse to "look at the bruises on my arm" A 52-year-old who has just had a bone marrow aspiration and is requesting pain medication A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism
A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism The client with the nosebleed may be experiencing the bleeding as a result of excessive anticoagulation and should be assessed for the severity of the situation first.
The nurse is caring for a group of hospitalized clients. Which client is at greatest risk for infection and sepsis? An 18-year-old who had an emergency splenectomy A 22-year-old with recently diagnosed sickle cell anemia A 38-year-old with hemolytic anemia A 40-year-old alcoholic with liver disease
An 18-year-old who had an emergency splenectomy Removal of the spleen causes reduced immune function. Without a spleen, the client is less able to remove disease-causing organisms, and is at increased risk for infection.
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
Applying pressure to the biopsy site The initial action should be to stop bleeding by applying pressure to the site. Inspecting for ecchymoses, sending specimens to the laboratory, and teaching the client about activity levels will be done after hemostasis has been achieved.
The 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
Has the client write down everything he or she has eaten for the past week Having the client provide a list of items eaten in the past week 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 protein, vitamin, and mineral intake.
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
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.
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? Hemoglobin level Platelet (thrombocyte) count Red blood cell (RBC) count White blood cell (WBC) response
Platelet (thrombocyte) count Platelet counts do not generally change with age. Hemoglobin levels in men and women fall after middle age; iron-deficient diets may play a role in this reduction. Total RBC and WBC counts (especially lymphocyte counts) are lower in older adults. The WBC count does not rise as high in response to infection in older adults as it does in younger people.
A client is scheduled for a bone marrow aspiration. What does the nurse do before taking the client to the treatment room for the biopsy? Clean the biopsy site with an antiseptic or povidone-iodine (Betadine). Hold the client's hand and ask about concerns. Review the client's platelet (thrombocyte) count. Verify that the client has given informed consent.
Verify that the client has given informed consent. Verifying informed consent must be done before the procedure can be performed. A signed permit must be on the client's chart. Reviewing the client's platelet count is not imperative.