Chapter 36: Assessment of the Hematologic
System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. 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.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Hematologic system, Patient safety, Diagnostic
testing MSC: Client Needs Category: Safe and Effective Care Environment:
Safety and Infection Control
, 2. 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)
ANS: C
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.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis
KEY: Hematologic system, Laboratory values MSC: Client
Needs Category: Safe and Effective Care Environment: Management of Care
3. 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.
DIF: Applying TOP: Integrated Process: Caring KEY:
Hematologic system, Psychosocial response, Anxiety, Support
MSC: Client Needs Category: Psychosocial Integrity
System
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. 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.
DIF: Applying TOP: Integrated Process: Nursing Process:
Implementation KEY: Hematologic system, Patient safety, Diagnostic
testing MSC: Client Needs Category: Safe and Effective Care Environment:
Safety and Infection Control
, 2. 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)
ANS: C
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.
DIF: Analyzing TOP: Integrated Process: Nursing Process: Analysis
KEY: Hematologic system, Laboratory values MSC: Client
Needs Category: Safe and Effective Care Environment: Management of Care
3. 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.
DIF: Applying TOP: Integrated Process: Caring KEY:
Hematologic system, Psychosocial response, Anxiety, Support
MSC: Client Needs Category: Psychosocial Integrity
