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NUR 504 Exam 3 With 100% Correct And Verified Answers 2024
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NUR 504 Exam 3 With 100% Correct And Verified Answers 2024
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NUR 504 Exam 3 With 100% Correct AndVerified 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 - Correct Answer-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. - Correct Answer-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
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,(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. - Correct Answer-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. - Correct Answer-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.
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,c. Check the pressure dressing frequently for signs of excessive
or active bleeding.
d. Report the laboratory results to the primary health care
provider. - Correct Answer-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) - Correct Answer-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. - Correct
Answer-ANS: A
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, 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. - Correct Answer-
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
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