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)
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
2. The nurse assesses a patient who has numerous petechial 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 ecchymosis. Ant seizure 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)
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
3. A nurse reviews the laboratory data for an older patient. The nurse would bemost concerned about
which
finding?
, a. Hematocrit of 35%
Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 325
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)
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)
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
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