Deck 32: Nursing Assessment Hematological System

Question 1

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.

Answer 1

Check temperature every 4 hours.

Question 2

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.

Answer 2

Apply a pressure dressing on the aspiration site.

Question 3

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

Answer 3

Pinpoint purplish-red lesions

Question 4

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 * 10?/L
B)Hematocrit of 37%
C)Platelet count of 400 * 10?/L
D)Hemoglobin of 118 g/L

Question 5

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

Question 6

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)

Question 7

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 * 10?/L
D) White blood cells 13.5 * 10?/L

Question 8

Aclient'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?"

Question 9

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

Question 10

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

Question 11

The nurse is reviewing the laboratory results of clotting study tests for the client. Which of the following findings should the nurse identify as abnormal? (Select all that apply.)

A)Activated clotting time 118 seconds
B)Activated partial thromboplastin time 40 seconds
C)D-dimer 200 mcg/L
D)Fibrinogen 5 g/L
E)Prothrombin time 21 seconds

Question 12

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

Question 13

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)

Question 14

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

Question 15

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.

Question 16

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