NUR 504 EXAM 3 QUESTIONS WITH
CORRECT ANSWERS
The nurse is assessing an older client for any potential hematologic health problem. Which a
qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
ssessment finding is the most significant and would be reported to the primary health care
w qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
provider?
w
a. Poor skin turgor on both forearms qw qw qw qw qw
b. Multiple petechiae and large bruises qw qw qw qw
c. Dry, flaky skin on arms and legs
qw qw qw qw qw qw
d. Decreased body hair distribution - correct answersANS: B qw qw qw qw qw qw qw
The presence of multiple petechiae and large bruises indicate a possible problem with blood
qw qw qw qw qw qw qw qw qw qw qw qw qw q
w clotting. Older adults typically have poor skin turgor and dry, flaky skin due to decreased body
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
w fluid as a result of aging. They also lose body hair or have thinning hair as a normal change of
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
w aging.
A nurse is assessing a dark-
qw qw qw qw qw
skinned client for pallor. What nursing assessment is best to assess for pallor in this client?
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
a. Assess the conjunctiva of the eye. qw qw qw qw qw
b. Have the patient open the hand widely. qw qw qw qw qw qw
c. Look at the roof of the patient's mouth.
qw qw qw qw qw qw qw
d. Palpate for areas of mild swelling. - correct answersANS: A qw qw qw qw qw qw qw qw qw
To assess pallor in dark-skinned people, assess the conjunctiva of the eye or the mucous
qw qw qw qw qw qw qw qw qw qw qw qw qw qw
membranes. Looking at the roof of the mouth can reveal jaundice. Opening the hand widely is qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
not related to pallor, nor is palpating for mild swelling.
qw qw qw qw qw qw qw qw qw
A hospitalized client has a platelet count of 58,000/mm3
qw qw qw qw qw qw qw qw
(58 × 109/L). What action by the nurse is most appropriate?
qw qw qw qw q w qw qw qw qw qw
a. Encouragehigh-protein foods. w
q w
q
b. Institute neutropenicprecautions. w
q w
q
c. Limit visitors to healthy adults. qw qw qw qw
d. Place the client on safety precautions. - correct answersANS: D
qw qw qw qw qw qw qw qw qw
,With a platelet count between 40,000 and 80,000/mm3
qw qw qw qw qw qw qw
(40 and 80 × 109 /L), clients are at risk of prolonged bleeding even after minor trauma. The nurse
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
would place the client on safety or bleeding precautions as the most appropriate actio
w qw qw qw qw qw qw qw qw qw qw qw qw qw
n. High- q w
protein foods, while healthy, are not the priority. Neutropenic precautions are not needed a s
q w q w q w q w q w q w q w q w q w q w q w q w q w q w q
the patient's white blood cell count is not low. Limiting visitors would also be more likely r
w q w q w q w q w q w q w q w q w q w q w q w q w q w q w q w q w q
elated to a low white blood cell count.
w qw qw qw qw qw qw qw
A client is having a bone marrow aspiration and biopsy. What action by the nurse takes
q w q w q w q w q w q w q w q w q w q w q w q w q w q w q w q
w priority?
a. Administer pain medication first. qw qw qw
b. Ensure that valid consent is in the medical record. qw qw qw qw qw qw qw qw
c. Have the client shower in the morning. qw qw qw qw qw qw
d. Premedicate the client with sedatives. - correct answersANS: B qw qw qw qw qw qw qw qw
A bone marrow aspiration and biopsy is an invasive procedure that requires informed conse nt.
qw qw qw qw qw qw qw qw qw qw qw qw qw qw
Pain medication and sedation are important components of care for this client but do not ta ke
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
priority. The client may or may not need or be able to shower. qw qw qw qw qw qw qw qw qw qw qw qw
What is the nurse's priority when caring for a client who just completed a bone marrow aspi
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
ration and biopsy?
w qw qw
a. Teach the client to avoid activity for 24 to 48 hours to prevent infection.
qw qw qw qw qw qw qw qw qw qw qw qw qw
b. Administer a nonsteroidal anti-inflammatory drug (NSAID) to promote comfort. qw qw qw qw qw qw qw qw
c. Check the pressure dressing frequently for signs of excessive or active bleeding.
qw qw qw qw qw qw qw qw qw qw qw
d. Report the laboratory results to the primary health care provider. - correct answersANS: C
qw qw qw qw qw qw qw qw qw qw qw qw qw
The client having a bone marrow aspiration and biopsy has a puncture wound from the larg e
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
needle used to extract the bone marrow. Therefore, the client is at risk for bleeding. A NSAI D
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
should not be given because it can cause bleeding. Avoiding activity helps to prevent
qw qw qw qw qw qw qw qw qw qw qw qw qw
bleeding, not infection, and reporting the results of the biopsy is not the responsibility of th e
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
,nurse.
A nurse is caring for four clients. After reviewing today's laboratory results, which client wou ld
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
the nurse assess first?
w qw qw qw
a. Client with an international normalized ratio of 2.8
qw qw qw qw qw qw qw
b. Client with a platelet count of 128,000/mm3 (128 × 109/L).
qw qw qw qw qw qw q w q w qw
c. Client with a prothrombin time (PT) of 28 seconds
qw qw qw q w qw qw qw qw
d. Client with a red blood cell count of 5.1 million/mcL (5.1 × 1012/L) -
qw qw qw q w q w qw qw q w qw qw qw qw qw
correct answersA normal PT is 11 to 12.5 seconds. This client is at high risk of bleeding with a PT
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
of 28 seconds. The other values are within normal limits.
w qw qw qw qw qw qw qw qw qw
A client is having a bone marrow aspiration and biopsy and is extremely anxious. What actio n
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
by the nurse is the most appropriate?
qw qw q w qw qw qw
a. Assess the client's fears and coping mechanisms. qw qw qw qw qw qw
b. Reassure the client that this is a common test. qw qw qw qw qw qw qw qw
c. Sedate the client prior to the procedure. qw qw qw qw qw qw
d. Tell the client that he or she will be asleep. - correct answersANS: A
qw qw qw qw qw qw qw qw qw qw qw qw qw
Assessing the client's specific fears and coping mechanisms helps guide the nurse in providing
qw qw qw qw qw qw qw qw qw qw qw qw qw q
w holistic care that best meets the client's needs. Reassurance will be helpful but is not the best
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
w option. Sedation is usually used. The client may or may not be totally asleep during the
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
w procedure.
A client is having a radioisotopic imaging scan. What action by the nurse is most important?
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
a. Assess the client for shellfish allergies. qw qw qw qw qw
b. Place the client on radiation precautions.qw qw qw qw qw
c. Sedate the client before the scan. qw qw qw qw qw
d. Teach the client about the procedure. - correct answersANS: D
qw qw qw qw qw qw qw qw qw
The nurse should ensure that teaching is done and the client understands the procedure.
qw qw qw qw qw qw qw qw qw qw qw qw qw q
w Contrast dye is not used, so shellfish/iodine allergies are not related. The client will not be
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
w radioactive and does not need radiation precautions. Sedation is not used in this procedure.
qw qw qw qw qw qw qw qw qw qw qw qw qw
, While taking a client history, which factor(s) that place the client at riskAfor a hematologic he alth
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
problem will the nurse document? (Select all that apply.)
w qw qw qw qw qw qw qw qw
a. Family history of bleeding problems qw qw qw qw
b. Diet low in iron and protein
qw qw qw q w q w
c. Excessive alcohol consumption qw qw
d. Family history of allergies qw qw qw
e. Diet high in saturated fatsqw qw qw qw
f. Diet high in Vitamin K - correct answersANS: A, C, F
qw qw q w q w qw qw qw q w qw qw
A family history of bleeding problems places the client at risk for having a similar problem.
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
w Excessive alcohol can damage the liver where prothrombin is produced. A diet high in
qw qw qw qw qw qw qw qw qw qw qw qw qw
Vitamin K can cause excessive clotting because it is a major clotting factor.
qw qw qw qw qw qw qw qw qw qw qw qw
An older client asks the nurse why "people my age" have weaker immune systems than younger
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
w people. What responses by the nurse are best? (Select all that apply.)
qw qw qw qw qw qw qw qw qw qw qw
a. "Bone marrow produces fewer blood cells as you age." qw qw qw qw qw qw qw qw
b. "You may have decreased levels of circulating platelets."
qw qw qw qw qw qw qw
c. "You have lower levels of plasma proteins in the blood."
qw qw qw qw qw qw qw qw qw
d. "Lymphocytes become more reactive to antigens." qw qw qw qw qw
e. "Spleen function declines after age 60." - correct answersANS: A, C qw qw qw qw qw qw qw qw qw qw
The aging adult has bone marrow that produces fewer cells and decreased blood volume wi th
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
fewer plasma proteins. Platelet numbers remain unchanged, lymphocytes become less reactive,
qw qw qw qw qw qw qw qw qw qw q
w and spleen function stays the same.
qw qw qw qw qw
The nurse is assessing a client experiencing anemia. Which laboratory findings will the nurse
qw qw qw qw qw qw qw qw qw qw qw qw qw q
expect for this client? (Select all that apply.)
w qw qw qw qw qw qw qw
a. Increased hematocrit qw
b. Decreased red blood cell count qw qw qw qw
c. Decreased serum iron qw qw
d. Decreased hemoglobin qw
e. Increased platelet count w
q qw
CORRECT ANSWERS
The nurse is assessing an older client for any potential hematologic health problem. Which a
qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
ssessment finding is the most significant and would be reported to the primary health care
w qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
provider?
w
a. Poor skin turgor on both forearms qw qw qw qw qw
b. Multiple petechiae and large bruises qw qw qw qw
c. Dry, flaky skin on arms and legs
qw qw qw qw qw qw
d. Decreased body hair distribution - correct answersANS: B qw qw qw qw qw qw qw
The presence of multiple petechiae and large bruises indicate a possible problem with blood
qw qw qw qw qw qw qw qw qw qw qw qw qw q
w clotting. Older adults typically have poor skin turgor and dry, flaky skin due to decreased body
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
w fluid as a result of aging. They also lose body hair or have thinning hair as a normal change of
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
w aging.
A nurse is assessing a dark-
qw qw qw qw qw
skinned client for pallor. What nursing assessment is best to assess for pallor in this client?
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
a. Assess the conjunctiva of the eye. qw qw qw qw qw
b. Have the patient open the hand widely. qw qw qw qw qw qw
c. Look at the roof of the patient's mouth.
qw qw qw qw qw qw qw
d. Palpate for areas of mild swelling. - correct answersANS: A qw qw qw qw qw qw qw qw qw
To assess pallor in dark-skinned people, assess the conjunctiva of the eye or the mucous
qw qw qw qw qw qw qw qw qw qw qw qw qw qw
membranes. Looking at the roof of the mouth can reveal jaundice. Opening the hand widely is qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
not related to pallor, nor is palpating for mild swelling.
qw qw qw qw qw qw qw qw qw
A hospitalized client has a platelet count of 58,000/mm3
qw qw qw qw qw qw qw qw
(58 × 109/L). What action by the nurse is most appropriate?
qw qw qw qw q w qw qw qw qw qw
a. Encouragehigh-protein foods. w
q w
q
b. Institute neutropenicprecautions. w
q w
q
c. Limit visitors to healthy adults. qw qw qw qw
d. Place the client on safety precautions. - correct answersANS: D
qw qw qw qw qw qw qw qw qw
,With a platelet count between 40,000 and 80,000/mm3
qw qw qw qw qw qw qw
(40 and 80 × 109 /L), clients are at risk of prolonged bleeding even after minor trauma. The nurse
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
would place the client on safety or bleeding precautions as the most appropriate actio
w qw qw qw qw qw qw qw qw qw qw qw qw qw
n. High- q w
protein foods, while healthy, are not the priority. Neutropenic precautions are not needed a s
q w q w q w q w q w q w q w q w q w q w q w q w q w q w q
the patient's white blood cell count is not low. Limiting visitors would also be more likely r
w q w q w q w q w q w q w q w q w q w q w q w q w q w q w q w q w q
elated to a low white blood cell count.
w qw qw qw qw qw qw qw
A client is having a bone marrow aspiration and biopsy. What action by the nurse takes
q w q w q w q w q w q w q w q w q w q w q w q w q w q w q w q
w priority?
a. Administer pain medication first. qw qw qw
b. Ensure that valid consent is in the medical record. qw qw qw qw qw qw qw qw
c. Have the client shower in the morning. qw qw qw qw qw qw
d. Premedicate the client with sedatives. - correct answersANS: B qw qw qw qw qw qw qw qw
A bone marrow aspiration and biopsy is an invasive procedure that requires informed conse nt.
qw qw qw qw qw qw qw qw qw qw qw qw qw qw
Pain medication and sedation are important components of care for this client but do not ta ke
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
priority. The client may or may not need or be able to shower. qw qw qw qw qw qw qw qw qw qw qw qw
What is the nurse's priority when caring for a client who just completed a bone marrow aspi
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
ration and biopsy?
w qw qw
a. Teach the client to avoid activity for 24 to 48 hours to prevent infection.
qw qw qw qw qw qw qw qw qw qw qw qw qw
b. Administer a nonsteroidal anti-inflammatory drug (NSAID) to promote comfort. qw qw qw qw qw qw qw qw
c. Check the pressure dressing frequently for signs of excessive or active bleeding.
qw qw qw qw qw qw qw qw qw qw qw
d. Report the laboratory results to the primary health care provider. - correct answersANS: C
qw qw qw qw qw qw qw qw qw qw qw qw qw
The client having a bone marrow aspiration and biopsy has a puncture wound from the larg e
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
needle used to extract the bone marrow. Therefore, the client is at risk for bleeding. A NSAI D
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
should not be given because it can cause bleeding. Avoiding activity helps to prevent
qw qw qw qw qw qw qw qw qw qw qw qw qw
bleeding, not infection, and reporting the results of the biopsy is not the responsibility of th e
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
,nurse.
A nurse is caring for four clients. After reviewing today's laboratory results, which client wou ld
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
the nurse assess first?
w qw qw qw
a. Client with an international normalized ratio of 2.8
qw qw qw qw qw qw qw
b. Client with a platelet count of 128,000/mm3 (128 × 109/L).
qw qw qw qw qw qw q w q w qw
c. Client with a prothrombin time (PT) of 28 seconds
qw qw qw q w qw qw qw qw
d. Client with a red blood cell count of 5.1 million/mcL (5.1 × 1012/L) -
qw qw qw q w q w qw qw q w qw qw qw qw qw
correct answersA normal PT is 11 to 12.5 seconds. This client is at high risk of bleeding with a PT
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
of 28 seconds. The other values are within normal limits.
w qw qw qw qw qw qw qw qw qw
A client is having a bone marrow aspiration and biopsy and is extremely anxious. What actio n
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
by the nurse is the most appropriate?
qw qw q w qw qw qw
a. Assess the client's fears and coping mechanisms. qw qw qw qw qw qw
b. Reassure the client that this is a common test. qw qw qw qw qw qw qw qw
c. Sedate the client prior to the procedure. qw qw qw qw qw qw
d. Tell the client that he or she will be asleep. - correct answersANS: A
qw qw qw qw qw qw qw qw qw qw qw qw qw
Assessing the client's specific fears and coping mechanisms helps guide the nurse in providing
qw qw qw qw qw qw qw qw qw qw qw qw qw q
w holistic care that best meets the client's needs. Reassurance will be helpful but is not the best
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
w option. Sedation is usually used. The client may or may not be totally asleep during the
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
w procedure.
A client is having a radioisotopic imaging scan. What action by the nurse is most important?
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
a. Assess the client for shellfish allergies. qw qw qw qw qw
b. Place the client on radiation precautions.qw qw qw qw qw
c. Sedate the client before the scan. qw qw qw qw qw
d. Teach the client about the procedure. - correct answersANS: D
qw qw qw qw qw qw qw qw qw
The nurse should ensure that teaching is done and the client understands the procedure.
qw qw qw qw qw qw qw qw qw qw qw qw qw q
w Contrast dye is not used, so shellfish/iodine allergies are not related. The client will not be
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
w radioactive and does not need radiation precautions. Sedation is not used in this procedure.
qw qw qw qw qw qw qw qw qw qw qw qw qw
, While taking a client history, which factor(s) that place the client at riskAfor a hematologic he alth
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
problem will the nurse document? (Select all that apply.)
w qw qw qw qw qw qw qw qw
a. Family history of bleeding problems qw qw qw qw
b. Diet low in iron and protein
qw qw qw q w q w
c. Excessive alcohol consumption qw qw
d. Family history of allergies qw qw qw
e. Diet high in saturated fatsqw qw qw qw
f. Diet high in Vitamin K - correct answersANS: A, C, F
qw qw q w q w qw qw qw q w qw qw
A family history of bleeding problems places the client at risk for having a similar problem.
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
w Excessive alcohol can damage the liver where prothrombin is produced. A diet high in
qw qw qw qw qw qw qw qw qw qw qw qw qw
Vitamin K can cause excessive clotting because it is a major clotting factor.
qw qw qw qw qw qw qw qw qw qw qw qw
An older client asks the nurse why "people my age" have weaker immune systems than younger
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw q
w people. What responses by the nurse are best? (Select all that apply.)
qw qw qw qw qw qw qw qw qw qw qw
a. "Bone marrow produces fewer blood cells as you age." qw qw qw qw qw qw qw qw
b. "You may have decreased levels of circulating platelets."
qw qw qw qw qw qw qw
c. "You have lower levels of plasma proteins in the blood."
qw qw qw qw qw qw qw qw qw
d. "Lymphocytes become more reactive to antigens." qw qw qw qw qw
e. "Spleen function declines after age 60." - correct answersANS: A, C qw qw qw qw qw qw qw qw qw qw
The aging adult has bone marrow that produces fewer cells and decreased blood volume wi th
qw qw qw qw qw qw qw qw qw qw qw qw qw qw qw
fewer plasma proteins. Platelet numbers remain unchanged, lymphocytes become less reactive,
qw qw qw qw qw qw qw qw qw qw q
w and spleen function stays the same.
qw qw qw qw qw
The nurse is assessing a client experiencing anemia. Which laboratory findings will the nurse
qw qw qw qw qw qw qw qw qw qw qw qw qw q
expect for this client? (Select all that apply.)
w qw qw qw qw qw qw qw
a. Increased hematocrit qw
b. Decreased red blood cell count qw qw qw qw
c. Decreased serum iron qw qw
d. Decreased hemoglobin qw
e. Increased platelet count w
q qw
