Deck 41: Assessment of the Hematologic System

Question 1

The nurse is teaching a client who has undergone a bone marrow biopsy.Which instruction does the nurse give the client?

A) "Wear protective gear when playing contact sports."
B) "Monitor the biopsy site for bruising."
C) "Remain in bed for at least 12 hours."
D) "Use a heating pad for pain at the biopsy site."

Answer 1

"Monitor the biopsy site for bruising."

Question 2

The nurse is assessing a client with numerous areas of bruising.Which question does the nurse ask to determine the cause of this finding?

A) "Do you take aspirin?"
B) "How often do you exercise?"
C) "Are you a vegetarian?"
D) "How often do you take Tylenol?"

Answer 2

"Do you take aspirin?"

Question 3

A client who has a chronic vitamin B₁₂ deficiency is admitted to the hospital.When obtaining the client's health history,which priority question does the nurse ask this client?

A) "Are you having any pain?"
B) "Are you having blood in your stools?"
C) "Do you notice any changes in your memory?"
D) "Do you bruise easily?"

Answer 3

"Do you notice any changes in your memory?"

Question 4

A female client is admitted with the medical diagnosis of anemia.The nurse assesses for which potential cause?

A) Diet high in meat and fat
B) Daily intake of aspirin
C) Heavy menses
D) Smoking history

Question 5

The nurse helps to ambulate a client who has anemia.Which clinical manifestation indicates that the client is not tolerating the activity?

A) Blood pressure of 120/90 mm Hg
B) Heart rate of 110 beats/min
C) Pulse oximetry reading of 95%
D) Respiratory rate of 20 breaths/min

Question 6

The nurse is caring for a client who is receiving heparin therapy.How does the nurse evaluate the therapeutic effect of the therapy?

A) Evaluate platelets.
B) Monitor the partial thromboplastin time (PTT).
C) Assess bleeding time.
D) Monitor fibrin degradation products.

Question 7

The nurse is completing the preoperative checklist on a client.The client states,"I take an aspirin every day for my heart." How does the nurse respond?

A) "I will call your doctor and request a prescription for pain medication."
B) "I need to call the surgeon and reschedule your surgery."
C) "I'll give you the prescribed Tylenol to minimize any headache before surgery."
D) "I need to administer vitamin K to prevent bleeding during the procedure."

Question 8

The nurse is caring for a client who has a decreased serum iron level.Which intervention does the nurse prioritize for this client?

A) Dietary consult
B) Family assessment
C) Cardiac assessment
D) Administration of vitamin K

Question 9

The nurse is assessing a client with liver failure.Which assessment is the highest priority for this client?

A) Auscultation for bowel sounds
B) Assessing for deep vein thrombosis
C) Monitoring of blood pressure hourly
D) Assessing for signs of bleeding

Question 10

The nurse is administering a prescribed fibrinolytic to a client who is having a myocardial infarction (MI).Which adverse effect does the nurse monitor for?

A) Bleeding
B) Orthostatic hypotension
C) Deep vein thrombosis
D) Nausea and vomiting

Question 11

The nurse is caring for a client who is receiving chemotherapy for cancer.Which intervention does the nurse implement for this client?

A) Assess the client's fibrinogen level.
B) Administer the prescribed iron.
C) Maintain strict Standard Precautions.
D) Monitor the client's pulse oximetry.

Question 12

The nurse is planning discharge teaching for a client who has a splenectomy.Which statement does the nurse include in this client's teaching plan?

A) "Avoid crowds and people who are sick."
B) "Do not eat raw fruits or vegetables."
C) "Avoid environmental allergens."
D) "Do not play contact sports."

Question 13

The nurse is assessing a client whose warfarin (Coumadin)therapy was discontinued 3 weeks ago.Which laboratory test result indicates that the client's warfarin therapy is no longer therapeutic?

A) International normalized ratio (INR), 0.9
B) Reticulocyte count, 1%
C) Serum ferritin level, 350 ng/mL
D) Total white blood cell (WBC) count, 9000/mm³

Question 14

The nurse is planning care for a client who has a platelet count of 30,000/mm³.Which intervention does the nurse include in this client's plan of care?

A) Oxygen by nasal cannula
B) Bleeding Precautions
C) Isolation Precautions
D) Vital signs every 4 hours

Question 15

The nurse is performing an admission assessment on a 46-year-old client,who states,"I have been drinking a 12-pack of beer every day for the past 20 years." Which laboratory abnormality does the nurse correlate with this history?

A) Decreased white blood cell (WBC) count
B) Decreased bleeding time
C) Elevated prothrombin time (PT)
D) Elevated red blood cell (RBC) count

Question 16

The nurse is assessing a client's susceptibility to rejecting a transplanted kidney.Which result does the nurse recognize as increasing the client's chances of rejection?

A) Decreased T-lymphocyte helper
B) Decreased white blood cell count
C) Increased cytotoxic-cytolytic T cell
D) Increased neutrophil count

Question 17

The nurse is assessing a 75-year-old male client.Which blood value indicates that the client is experiencing normal changes associated with aging?

A) Hemoglobin, 13.0 g/dL
B) Platelet count, 100,000/mm³
C) Prothrombin time (PT), 14 seconds
D) White blood cell (WBC) count, 5000/mm³

Question 18

The nurse observes yellow-tinged sclera in a client with dark skin.Based on this assessment finding,what does the nurse do next?

A) Assess the client's pulses.
B)Examine the soles of the client's feet.
C)Inspect the client's hard palate.
D)Auscultate the client's lung sounds.

Question 19

The nurse is obtaining the health history of a client who has iron deficiency anemia.Which factor in this client's history does the nurse correlate with this diagnosis?

A) Eating a meat-free diet
B) Family history of sickle cell disease
C) History of leukemia
D) History of bleeding ulcer

Question 20

The nurse is caring for a client who has an elevated white blood cell count.Which intervention does the nurse implement for this client?

A) Administer the prescribed Tylenol.
B) Hold the client's prescribed steroids.
C) Assess the client's respiratory rate.
D) Obtain the client's temperature.

Question 21

The nurse is assessing the following laboratory results of a client before discharge.Which instruction does the nurse include in this client's discharge teaching plan?

A) "Avoid contact sports."
B) "Do not take any aspirin."
C) "Eat a diet high in iron."
D) "Perform good hand hygiene."

Question 22

The nurse is caring for four clients with hematologic-type problems.Which client does the nurse prioritize to see first?

A) 18-year-old female with decreased protein levels
B) 36-year-old male with increased lymphocytes
C) 60-year-old female with decreased erythropoietin
D) 82-year-old male with an increased thromboxane level

Question 23

The nurse is monitoring a client with liver failure.Which assessments does the nurse perform when monitoring for bleeding in this client?

A) Gums
B) Lung sounds
C) Urine
D) Stool
E) Hair

Question 24

The nurse is preparing a client for a bone biopsy and aspiration.The client asks,"Will this be painful?" How does the nurse respond?

A) "The procedure is always done under general anesthesia."
B) "The biopsy lasts for only 2 minutes."
C) "There is a chance that you may have pain."
D) "You can relieve pain with guided imagery."

Question 25

The nurse is teaching a client who is receiving sodium warfarin (Coumadin).Which topics does the nurse include in the teaching plan?

A) Foods high in vitamin K
B) Using acetaminophen (Tylenol) for minor pain
C) Daily exercise and weight management
D) Use of a safety razor and soft toothbrush
E) Blood testing regimen

Question 26

The nurse is caring for a client who had a bone marrow aspiration.The client begins to bleed from the aspiration site.Which action does the nurse perform?

A) Apply external pressure to the site.
B) Elevate the extremities.
C) Cover the site with a dressing.
D) Immobilize the leg.