Chapter 39: Assessment of the Hematologic System Nursing School Test Banks

Chapter 39: Assessment of the Hematologic System
Ignatavicius: Medical-Surgical Nursing, 8th Edition

MULTIPLE CHOICE

1. A nursing student wants to know why clients with chronic obstructive pulmonary disease tend to be polycythemic. What response by the nurse instructor is best?
a. It is due to side effects of medications for bronchodilation.
b. It is from overactive bone marrow in response to chronic disease.
c. It combats the anemia caused by an increased metabolic rate.
d. It compensates for tissue hypoxia caused by lung disease.
ANS: D
In response to hypoxia, more red blood cells are made so more oxygen can be carried and delivered to tissues. This is a physiologic process in response to the disease; it is not a medication side effect, the result of overactive bone marrow, or a response to anemia.

DIF: Remembering/Knowledge REF: 787
KEY: Hematologic system| pathophysiology
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. A client is receiving rivaroxaban (Xarelto) and asks the nurse to explain how it works. What response by the nurse is best?
a. It inhibits thrombin.
b. It inhibits fibrinogen.
c. It thins your blood.
d. It works against vitamin K.
ANS: A
Rivaroxaban is a direct thrombin inhibitor. It does not work on fibrinogen or vitamin K. It is not a blood thinner, although many clients call anticoagulants by this name.

DIF: Understanding/Comprehension REF: 791
KEY: Hematologic system| anticoagulants
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

3. The health care provider tells the nurse that a client is to be started on a platelet inhibitor. About what drug does the nurse plan to teach the client?
a. Clopidogrel (Plavix)
b. Enoxaparin (Lovenox)
c. Reteplase (Retavase)
d. Warfarin (Coumadin)
ANS: A
Clopidogrel is a platelet inhibitor. Enoxaparin is an indirect thrombin inhibitor. Reteplase is a fibrinolytic agent. Warfarin is a vitamin K antagonist.

DIF: Remembering/Knowledge REF: 791
KEY: Hematologic system| anticoagulants
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

4. A nurse is assessing a dark-skinned client for pallor. What action is best?
a. Assess the conjunctiva of the eye.
b. Have the client open the hand widely.
c. Look at the roof of the clients mouth.
d. Palpate for areas of mild swelling.
ANS: A
To assess pallor in dark-skinned people, assess the conjunctiva of the eye or the mucous membranes. Looking at the roof of the mouth can reveal jaundice. Opening the hand widely is not related to pallor, nor is palpating for mild swelling.

DIF: Applying/Application REF: 791
KEY: Hematologic system| nursing assessment| anemia
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A hospitalized client has a platelet count of 58,000/mm3. What action by the nurse is best?
a. Encourage high-protein foods.
b. Institute neutropenic precautions.
c. Limit visitors to healthy adults.
d. Place the client on safety precautions.
ANS: D
With a platelet count between 40,000 and 80,000/mm3, clients are at risk of prolonged bleeding even after minor trauma. The nurse should place the client on safety precautions. High-protein foods, while healthy, are not the priority. Neutropenic precautions are not needed as the clients white blood cell count is not low. Limiting visitors would also be more likely related to a low white blood cell count.

DIF: Applying/Application REF: 792
KEY: Hematologic system| client safety| laboratory values
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

6. A client is having a bone marrow biopsy today. What action by the nurse takes priority?
a. Administer pain medication first.
b. Ensure valid consent is on the chart.
c. Have the client shower in the morning.
d. Premedicate the client with sedatives.
ANS: B
A bone marrow biopsy is an invasive procedure that requires informed consent. Pain medication and sedation are important components of care for this client but do not take priority. The client may or may not need or be able to shower.

DIF: Applying/Application REF: 795
KEY: Hematologic system| informed consent
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care

7. A nurse is caring for four clients. After reviewing todays laboratory results, which client should the nurse see first?
a. Client with an international normalized ratio of 2.8
b. Client with a platelet count of 128,000/mm3
c. Client with a prothrombin time (PT) of 28 seconds
d. Client with a red blood cell count of 5.1 million/L
ANS: C
A normal PT is 11 to 12.5 seconds. This client is at high risk of bleeding. The other values are within normal limits.

DIF: Applying/Application REF: 795
KEY: Hematologic system| laboratory values
MSC: Integrated Process: Nursing Process: Analysis
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

8. A client is having a bone marrow biopsy and is extremely anxious. What action by the nurse is best?
a. Assess client fears and coping mechanisms.
b. Reassure the client this is a common test.
c. Sedate the client prior to the procedure.
d. Tell the client he or she will be asleep.
ANS: A
Assessing the clients specific fears and coping mechanisms helps guide the nurse in providing holistic care that best meets the clients needs. Reassurance will be helpful but is not the best option. Sedation is usually used. The client may or may not be totally asleep during the procedure.

DIF: Applying/Application REF: 795
KEY: Hematologic system| psychosocial response| caring| anxiety| support
MSC: Integrated Process: Caring
NOT: Client Needs Category: Psychosocial Integrity

9. 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.
ANS: D
The nurse should ensure that teaching is done and the client understands the procedure. Contrast dye is not used, so shellfish/iodine allergies are not related. The client will not be radioactive and does not need radiation precautions. Sedation is not used in this procedure.

DIF: Applying/Application REF: 765
KEY: Hematologic system| patient education
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE

1. A student nurse learns that the spleen has several functions. What functions do they include? (Select all that apply.)
a. Breaks down hemoglobin
b. Destroys old or defective red blood cells (RBCs)
c. Forms vitamin K for clotting
d. Stores extra iron in ferritin
e. Stores platelets not circulating
ANS: A, B, E
Functions of the spleen include breaking down hemoglobin released from RBCs, destroying old or defective RBCs, and storing the platelets that are not in circulation. Forming vitamin K for clotting and storing extra iron in ferritin are functions of the liver.

DIF: Remembering/Knowledge REF: 787
KEY: Hematologic system MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

2. 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.
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.
ANS: A, C
The aging adult has bone marrow that produces fewer cells and decreased blood volume with fewer plasma proteins. Platelet numbers remain unchanged, lymphocytes become less reactive, and spleen function stays the same.

DIF: Understanding/Comprehension REF: 788
KEY: Hematologic system MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Health Promotion and Maintenance

3. A nursing student learns that many drugs can impair the immune system. Which drugs does this include? (Select all that apply.)
a. Acetaminophen (Tylenol)
b. Amphotericin B (Fungizone)
c. Ibuprofen (Motrin)
d. Metformin (Glucophage)
e. Nitrofurantoin (Macrobid)
ANS: B, C, E
Amphotericin B, ibuprofen, and nitrofurantoin all can disrupt the hematologic (immune) system. Acetaminophen and metformin do not.

DIF: Remembering/Knowledge REF: 791
KEY: Hematologic system| adverse effects
MSC: Integrated Process: Teaching/Learning
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

4. A nurse works in a gerontology clinic. What age-related changes cause the nurse to alter standard assessment techniques from those used for younger adults? (Select all that apply.)
a. Dentition deteriorates with more cavities.
b. Nail beds may be thickened or discolored.
c. Progressive loss of hair occurs with age.
d. Sclerae begin to turn yellow or pale.
e. Skin becomes dry as the client ages.
ANS: B, C, E
Common findings in older adults include thickened or discolored nail beds, dry skin, and thinning hair. The nurse adapts to these changes by altering assessment techniques. Having more dental caries and changes in the sclerae are not normal age-related changes.

DIF: Remembering/Knowledge REF: 790
KEY: Hematologic system| older adult| nursing assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance

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