Chapter 36 Practice Questions - Assessment of the Hematologic System Flashcards
The nurse is assessing an older client for any potential hematologic health problem. Which assessment finding is the most significant and would be reported to the primary health care provider?
a. Poor skin turgor on both forearms
b. Multiple petechiae and large bruises
c. Dry, flaky skin on arms and legs
d. Decreased body hair distribution
b. Multiple petechiae and large bruises
A nurse is assessing a dark-skinned client for pallor. What nursing assessment is best to assess for pallor in this client?
a. Assess the conjunctiva of the eye.
b. Have the patient open the hand widely.
c. Look at the roof of the patient’s mouth.
d. Palpate for areas of mild swelling
a. Assess the conjunctiva of the eye.
A hospitalized client has a platelet count of 58,000/mm3
(58 109/L). What action by the nurse is most appropriate?
a. Encourage high-protein foods.
b. Institute neutropenic precautions.
c. Limit visitors to healthy adults.
d. Place the client on safety precautions.
d. Place the client on safety precautions.
A client is having a bone marrow aspiration and biopsy. What action by the nurse takes priority?
a. Administer pain medication first.
b. Ensure that valid consent is in the medical record.
c. Have the client shower in the morning.
d. Premedicate the client with sedatives.
b. Ensure that valid consent is in the medical record.
What is the nurse’s priority when caring for a client who just completed a bone marrow aspiration and biopsy?
a. Teach the client to avoid activity for 24 to 48 hours to prevent infection.
b. Administer a nonsteroidal anti-inflammatory drug (NSAID) to promote comfort.
c. Check the pressure dressing frequently for signs of excessive or active bleeding.
d. Report the laboratory results to the primary health care provider.
c. Check the pressure dressing frequently for signs of excessive or active bleeding.
A nurse is caring for four clients. After reviewing today’s laboratory results, which client would the nurse assess first?
a. Client with an international normalized ratio of 2.8
b. Client with a platelet count of 128,000/mm3
(128 109/L).
c. Client with a prothrombin time (PT) of 28 seconds
d. Client with a red blood cell count of 5.1 million/mcL (5.1 1012/L)
c. Client with a prothrombin time (PT) of 28 seconds
A client is having a bone marrow aspiration and biopsy and is extremely anxious. What action by the nurse is the most appropriate?
a. Assess the client’s fears and coping mechanisms.
b. Reassure the client that this is a common test.
c. Sedate the client prior to the procedure.
d. Tell the client that he or she will be asleep.
a. Assess the client’s fears and coping mechanisms.
A client is having a radioisotopic imaging scan. What action by the nurse is most important?
a. Assess the client for shellfish allergies.
b. Place the client on radiation precautions.
c. Sedate the client before the scan.
d. Teach the client about the procedure
d. Teach the client about the procedure
While taking a client history, which factor(s) that place the client at risk for a hematologicmhealth problem will the nurse document? (Select all that apply.)
a. Family history of bleeding problems
b. Diet low in iron and protein
c. Excessive alcohol consumption
d. Family history of allergies
e. Diet high in saturated fats
f. Diet high in Vitamin K
a. Family history of bleeding problems
c. Excessive alcohol consumption
f. Diet high in Vitamin K
An older client asks the nurse why “people my age” have weaker immune systems than younger people. What responses by the nurse are best? (Select all that apply.)
a. “Bone marrow produces fewer blood cells as you age.”
b. “You may have decreased levels of circulating platelets.”
c. “You have lower levels of plasma proteins in the blood.”
d. “Lymphocytes become more reactive to antigens.”
e. “Spleen function declines after age 60.”
a. “Bone marrow produces fewer blood cells as you age.”
c. “You have lower levels of plasma proteins in the blood.”
The nurse is assessing a client experiencing anemia. Which laboratory findings will the nurse expect for this client? (Select all that apply.)
a. Increased hematocrit
b. Decreased red blood cell count
c. Decreased serum iron
d. Decreased hemoglobin
e. Increased platelet count
f. Decreased white blood cell count
b. Decreased red blood cell count
c. Decreased serum iron
d. Decreased hemoglobin
A nurse works in a gerontology clinic. What age-related change(s) related to the hematologic system will the nurse expect during health assessment? (Select all that apply.)
a. Dentition deteriorates with more cavities.
b. Nail beds may be thickened or discolored.
c. Progressive loss or thinning of hair occurs.
d. Sclerae begin to turn yellow or pale.
e. Skin becomes more oily.
b. Nail beds may be thickened or discolored.
c. Progressive loss or thinning of hair occurs.
