Chapter 30: Nursing Assessment: Hematologic System Nursing School Test Banks

Chapter 30: Nursing Assessment: Hematologic System

Test Bank

MULTIPLE CHOICE

1. The nurse is caring for a patient who is being discharged after an emergency splenectomy following an automobile accident. Which instructions should the nurse include in the discharge teaching?

a.

Watch for excess bruising.

b.

Check for swollen lymph nodes.

c.

Take iron supplements to prevent anemia.

d.

Wash hands and avoid persons who are ill.

ANS: D

Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy.

DIF: Cognitive Level: Apply (application) REF: 618

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

2. The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient?

a.

Do you take salicylates?

b.

Are you taking any oral contraceptives?

c.

Have you been prescribed antiseizure drugs?

d.

How long have you taken antihypertensive drugs?

ANS: A

Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia, but not clotting disorders or bleeding. Oral contraceptives increase a persons clotting risk. Antihypertensives do not usually cause problems with decreased clotting.

DIF: Cognitive Level: Understand (comprehension) REF: eTable 30-1

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

3. A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding?

a.

Hematocrit of 35%

b.

Hemoglobin of 11.8 g/dL

c.

Platelet count of 400,000/L

d.

White blood cell (WBC) count of 2800/L

ANS: D

Because the total WBC count is not usually affected by aging, the low WBC count in this patient would indicate that the patients immune function may be compromised and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.

DIF: Cognitive Level: Apply (application) REF: 619

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

4. A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure?

a.

Elevate the head of the bed to 45 degrees.

b.

Apply a sterile 2-inch gauze dressing to the site.

c.

Use a half-inch sterile gauze to pack the wound.

d.

Have the patient lie on the left side for 1 hour.

ANS: D

To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patients head.

DIF: Cognitive Level: Apply (application) REF: 630

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

5. The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect?

a.

Yellow-tinged sclerae

b.

Shiny, smooth tongue

c.

Numbness of the extremities

d.

Gum bleeding and tenderness

ANS: C

Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.

DIF: Cognitive Level: Apply (application) REF: 622

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

6. A patients complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding?

a.

Have you had a recent weight loss?

b.

Do you have any history of lung disease?

c.

Have you noticed any dark or bloody stools?

d.

What is your dietary intake of meats and protein?

ANS: B

The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease (COPD). The other questions would be appropriate for patients who are anemic.

DIF: Cognitive Level: Apply (application) REF: 625

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

7. The nurse is reviewing laboratory results and notes an aPTT level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication?

a.

Aspirin

b.

Heparin

c.

Warfarin

d.

Erythropoietin

ANS: B

Activated partial thromboplastin time (aPTT) assesses intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, XII. aPTT is increased (prolonged) in heparin administration.

aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production.

DIF: Cognitive Level: Apply (application) REF: 626

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

8. When assessing a newly admitted patient, the nurse notes pallor of the skin and nail beds. The nurse should ensure that which laboratory test has been ordered?

a.

Platelet count

b.

Neutrophil count

c.

White blood cell count

d.

Hemoglobin (Hgb) level

ANS: D

Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a persons clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.

DIF: Cognitive Level: Apply (application) REF: 623

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

9. The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse?

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 patient with an infected foot

ANS: A

Enlarged and nontender nodes are suggestive of malignancies 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 to 1 cm and nontender.

DIF: Cognitive Level: Apply (application) REF: 622

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory result would the nurse expect to find?

a.

Hematocrit of 46%

b.

Hemoglobin of 13.8 g/dL

c.

Elevated reticulocyte count

d.

Decreased white blood cell (WBC) count

ANS: C

Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.

DIF: Cognitive Level: Understand (comprehension) REF: 615

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

11. The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action 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.

ANS: A

Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia.

DIF: Cognitive Level: Apply (application) REF: 626

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

12. The health care providers progress note for a patient states that the complete blood count (CBC) shows a shift to the left. Which assessment finding will the nurse expect?

a.

Cool extremities

b.

Pallor and weakness

c.

Elevated temperature

d.

Low oxygen saturation

ANS: C

The term shift to the left indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor/weakness, or cool extremities.

DIF: Cognitive Level: Apply (application) REF: 627

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

13. The health care provider orders a liver/spleen scan for a patient who has been in a motor vehicle accident. Which action should the nurse take before this procedure?

a.

Check for any iodine allergy.

b.

Insert a large-bore IV catheter.

c.

Place the patient on NPO status.

d.

Assist the patient to a flat position.

ANS: D

During a liver/spleen scan, a radioactive isotope is injected IV and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter is not needed. The patient is placed in a flat position before the scan.

DIF: Cognitive Level: Apply (application) REF: 629

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

14. A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test?

a.

ABO blood typing

b.

Bone marrow biopsy

c.

Abdominal ultrasound

d.

Complete blood count (CBC)

ANS: B

A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent by the patient or guardian.

DIF: Cognitive Level: Apply (application) REF: 629

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. The nurse reviews the complete blood count (CBC) and white blood cell (WBC) differential of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider?

a.

Monocytes 4%

b.

Hemoglobin 13.6 g/dL

c.

Platelet count 168,000/L

d.

White blood cells (WBCs) 15,500/L

ANS: D

The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patients pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.

DIF: Cognitive Level: Apply (application) REF: 627

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

16. Which information shown in the accompanying figure about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider?

a.

Platelet count

b.

White blood cell count

c.

History of abdominal pain

d.

Blood pressure and heart rate

ANS: A

The platelet count is severely decreased and places the patient at risk for spontaneous bleeding. The other information is also pertinent, but not as indicative of the need for rapid treatment as the platelet count.

DIF: Cognitive Level: Analyze (analysis) REF: 627

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

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