Chapter 32 Flashcards
The nurse is providing discharge teaching to a client who has had an emergency splenectomy following an automobile accident. Which of the following events should the nurse inform the client that they are at an increased risk of developing?
a. Infection
b. Lymphedema
c. Chronic anemia
d. Prolonged bleeding
A
The spleen plays a major role in immune function. 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 is obtaining a health history from a client and notes numerous petechiae. Which of the following assessments should the nurse anticipate?
a. Bruising on the skin
b. Pinpoint purplish-red lesions
c. Small focal red lesions
d. Brown spots on mucous membranes
B
Petechiae are small, purplish-red lesions. Ecchymosis is bruising on the skin. Small focal red lesions are telangiectasia. Purpura are small hemorrhages on the skin or mucous membranes resulting in a rash of purple, red, or brown spots.
The nurse is reviewing laboratory data for an older-adult client. Which of the following results should be of most concern?
a.White blood cell (WBC) count of 3.5 ́ b. Hematocrit of 37%
c.109/L Platelet count of 400 ́ 109/L
d. Hemoglobin of 118 g/L
A
The total WBC count is not usually affected by aging, and the low WBC here would indicate that the client’s immune function may be compromised. The platelet count is normal. The slight decrease in hemoglobin and hematocrit is not unusual for an older client.
The health care provider performs a bone marrow aspiration from the left posterior iliac crest on a client with pancytopenia. Which of the following actions should the nurse implement following the procedure?
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. Apply a pressure dressing on the aspiration site.
D
A pressure dressing is used to cover the aspiration site. The wound after bone marrow biopsy is small and will not be packed with gauze. There is no indication that the head needs to be elevated for this client.
DIF: Cognitive Level: Application
The nurse is caring for a client with a chronic iron-deficiency anemia. Which of the following assessment findings should the nurse anticipate?
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 thrombo-cytopenia or neutropenia, and extremity numbness is associated with vitamin B12 deficiency or pernicious anemia.
A client’s complete blood count shows a hemoglobin of 200 g/L and a hematocrit of 54%. Which of the following questions should the nurse ask to determine possible causes of this finding?
a. “Has there been any recent weight loss?”
b. “Do you have any problems with your vision?”
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 and polycythemia may cause visual abnormalities. The other questions will be appropriate for clients who are anemic
The nurse is caring for a client who is receiving heparin. Which of the following laboratory tests should the nurse 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.
The nurse is evaluating the red cell indices result of a client’s laboratory report. Which of the following interpretations is correct related to a low mean corpuscular volume (MCV)?
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).
While examining the lymph nodes during physical assessment, the nurse would be most concerned about which of the following findings?
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 client 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 0.5–1 cm and nontender.
The nurse is caring for a client who had an intraoperative hemorrhage 12 hours ago. Which of the following laboratory results should the nurse anticipate?
a. Hematocrit of 45%
b. Hemoglobin of 132 g/L
c. Decreased white blood cell (WBC) count
d. 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 whose complete blood count (CBC) and differential indicate that the client is neutropenic. Which of the following actions 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 clients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. The other actions would not address the client’s neutropenia.
The nurse is caring for a newly admitted client whose complete blood count (CBC) shows a “shift to the left.” Which of the following assessments should the nurse monitor in the plan of care?
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 client is at risk for hypoxemia, pallor or weakness, or cool extremities
The health care provider orders an ultrasound of the spleen for a client who has been in a car accident. Which of the following actions should the nurse take before this procedure?
a. Check for any iodine allergy.
b. Insert a large-bore IV catheter.
c. Place the client on NPO status.
d. Assist the client to a flat position.
D
The client is placed in a flat position before splenic ultrasound. The client does not have to be NPO or have an IV line. No iodine-containing materials are used for ultrasound.
The nurse is caring for a client with pancytopenia of unknown origin who is confused and is scheduled for the following diagnostic tests. Which of the following tests should the nurse contact the client’s family member to obtain a signed consent form?
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 client or guardian to sign a surgical consent form. The other procedures do not require a signed consent by the client or family.
The nurse is reviewing the complete blood count (CBC) for a client admitted with abdominal pain. Which of the following information will be most important for the nurse to communicate to the health care provider?
a. Monocytes 4%
b. Hemoglobin 116 g/L
c.
Platelet count 145 ́ 109/L
d. White blood cells 13.5 ́ 109/L
D
The elevation in WBCs indicates that an abdominal infection may be the cause of the client’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.
