NUR 504 Exam 3 Review Questions and Correct Answers
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NUR 504
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NUR 504
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 an...
NUR 504 Exam 3 Review Questions and
Correct Answers
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 ✅ANS: B
The presence of multiple petechiae and large bruises indicate a possible problem with
blood
clotting. Older adults typically have poor skin turgor and dry, flaky skin due to decreased
body fluid as a result of aging. They also lose body hair or have thinning hair as a
normal
change of aging.
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. ✅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.
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. ✅ANS: D
With a platelet count between 40,000 and 80,000/mm3
(40 and 80 × 109 /L), clients are at risk of prolonged bleeding even after minor trauma.
The nurse would place the client on safety or bleeding precautions as the most
appropriate action. High-protein foods, while healthy, are not the priority. Neutropenic
precautions are not needed as the patient's white blood cell count is not low. Limiting
visitors would also be more likely related to a low white blood cell count.
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. ✅ANS: B
A bone marrow aspiration and 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.
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. ✅ANS: C
The client having a bone marrow aspiration and biopsy has a puncture wound from the
large
needle used to extract the bone marrow. Therefore, the client is at risk for bleeding. A
NSAID
should not be given because it can cause bleeding. Avoiding activity helps to prevent
bleeding, not infection, and reporting the results of the biopsy is not the responsibility of
the
nurse.
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) ✅A normal PT is
11 to 12.5 seconds. This client is at high risk of bleeding with a PT of 28 seconds. The
other values are within normal limits.
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. ✅ANS: A
Assessing the client's specific fears and coping mechanisms helps guide the nurse in
providing holistic care that best meets the client's 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.
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.
While taking a client history, which factor(s) that place the client at risk for a hematologic
health 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 ✅ANS: A, C, F
A family history of bleeding problems places the client at risk for having a similar
problem.
Excessive alcohol can damage the liver where prothrombin is produced. A diet high in
Vitamin K can cause excessive clotting because it is a major clotting factor.
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." ✅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.
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 ✅ANS: B, C, D
Clients experiencing anemia have a decreased red blood cell count which leads to a
decreased
hemoglobin and hematocrit. For some clients, serum iron levels are also decreased.
Anemia is
not a problem involving platelets or white blood cells.
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. ✅ANS: B, C
Common findings in older adults include thickened or discolored nail beds, dry (not oily)
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.
A client has a platelet count of 9000/mm3
(9 × 109/L). The nurse finds the client confused and
mumbling. What nursing action takes priority at this time?
a. Call the Rapid Response Team.
b. Take a set of vital signs.
c. Institute bleeding precautions.
d. Place the client on bedrest. ✅ANS: A
With a platelet count this low, the client is at high risk of spontaneous bleeding. The
most
disastrous complication would be intracranial bleeding. The nurse needs to call the
Rapid
Response Team as this client has manifestations of a sudden neurologic change.
Bleeding
precautions will not address the immediate situation. Placing the client on bedrest is
important, but the critical action is to call for immediate medical attention.
A nurse assesses a client with diabetes mellitus who is admitted with an acid-base
imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2
33 mm Hg, and HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse
identify as an
example of the client's compensatory mechanisms?
a. Increased rate and depth of respirations
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