NUR 504 EXAM 3 QUESTIONS WITH CORRECT ANSWERS

NUR 504 EXAM 3 QUESTIONS WITH CORRECT ANSWERS



Thenurseisassessing anolderclientforanypotentialhematologichealthproblem.Whicha ssess
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ment finding is the most significant and would bereported to theprimaryhealth care provide
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r?

a. Poorskinturgoronbothforearms n
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b. Multiplepetechiaeandlargebruises n
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c. Dry,flakyskinonarms andlegs
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d. Decreasedbodyhairdistribution -correctanswersANS:B n
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Thepresenceof multiplepetechiae and largebruises indicateapossibleproblem withblood clott
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ing. Older adults typically havepoorskin turgor and dry, flakyskin duetodecreased body fluid as
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aresult of aging. They also losebodyhairorhavethinning hairasanormal change of aging.
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Anurseisassessing a dark- n
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skinnedclient forpallor.Whatnursingassessment isbesttoassess forpallor inthis client?
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a. Assesstheconjunctivaoftheeye. n
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b. Have the patientopen the hand widely. c n
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c. Lookat theroofofthepatient'smouth. cn n
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d. Palpateforareasofmildswelling.-correctanswersANS:A n
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Toassesspallorindark-
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skinned people,assesstheconjunctivaoftheeyeorthemucous membranes.Lookingattheroofof
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themouthcanrevealjaundice.Openingthehandwidelyis not relatedtopallor,norispalpatingfor
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mild swelling. cn




Ahospitalized clienthasaplateletcountof 58,000/mm3 (58 cn n
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×109/L).What actionbythenurseismost appropriate?
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a. Encouragehigh-proteinfoods.

b. Instituteneutropenicprecautions.

c. Limitvisitorstohealthyadults. n
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d. Placetheclient onsafetyprecautions.-correct answersANS:D
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,With aplateletcountbetween 40,000 and 80,000/mm3
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(40 and 80 × 109 /L), clients areat risk of prolonged bleeding even after minor trauma. Thenurse
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wouldplacethe client on safetyorbleedingprecautions asthe most appropriate actio n
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n.High- n
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protein foods, while healthy, are not the priority. Neutropenic precautions are not needed a s th
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e patient's white blood cell count is not low. Limiting visitors would also be more likely r elated
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toalowwhite blood cell count.
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A client is having a bone marrow aspiration and biopsy. What action by the nurse takes
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priority?

a. Administerpainmedication first. cn




b. Ensurethatvalidconsentisinthemedicalrecord. n
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c. Havetheclientshowerinthemorning. n
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d. Premedicatetheclientwithsedatives. - correct answersANS: B cn cn qw cn




Abonemarrowaspiration andbiopsyisan invasiveprocedurethatrequiresinformed conse nt. cn cn cn cn cn




Pain medication and sedation are important components ofcareforthis client butdonotta ke pr
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iority.The client mayormaynot need orbe able toshower.
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What is thenurse's priority when caring for aclient who just completed abonemarrow aspi ra
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tion andbiopsy? n
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a. Teachtheclientto avoidactivityfor 24 to48hourstopreventinfection. n
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b. Administeranonsteroidalanti-inflammatorydrug(NSAID)topromotecomfort. n
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c. Checkthepressuredressing frequentlyforsignsofexcessiveoractivebleeding. n
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d. Reportthelaboratoryresultstotheprimaryhealthcareprovider.-
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correctanswersANS:C Theclienthaving abonemarrowaspiration and biopsyhas apuncture n
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woundfrom the larg e needleused toextractthebonemarrow.Therefore,theclientisatrisk fo
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rbleeding.ANSAID should not be given because it can cause bleeding. Avoiding activityhelps
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toprevent bleeding,notinfection,and reportingthe results ofthebiopsyisnot theresponsibil
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ityofthe n
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,nurse.

Anurseiscaring forfourclients.Afterreviewing today'slaboratoryresults,which client wou ld th
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enurseassessfirst? n
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a. Clientwithaninternationalnormalizedratioof2.8 n
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b. Clientwitha platelet countof128,000/mm3 (128×109/L).
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c. Clientwithaprothrombin time(PT)of28seconds
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d. Clientwithared blood cellcountof 5.1 million/mcL(5.1×1012/L)-
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correctanswersA normalPTis11 to12.5seconds.Thisclient is at highrisk ofbleeding withaPT
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of 28 seconds. Theother values arewithin normal limits.
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Aclientishaving abonemarrowaspiration andbiopsyandisextremelyanxious.Whataction byth
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enurse is the most appropriate?
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a. Assesstheclient'sfearsandcopingmechanisms. n
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b. Reassuretheclientthat thisis acommon test. n
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c. Sedate the client prior totheprocedure. c n
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d. Telltheclientthatheorshewillbeasleep.-correctanswersANS: A
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Assessingtheclient'sspecific fearsandcopingmechanismshelpsguidethenurseinproviding holi
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sticcarethatbestmeetsthe client's needs.Reassurance willbehelpfulbut is notthebest option.
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Sedation is usually used. The client mayormaynot betotallyasleepduringthe procedure.
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Aclientishaving aradioisotopic imaging scan.What actionbythenurseismostimportant?
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a. Assesstheclientforshellfish allergies. n
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b. Placethe client onradiation precautions.
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c. Sedatetheclientbefore thescan. n
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d. Teachthe clientabout theprocedure.- correctanswersANS:D n
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Thenurse should ensure that teaching is doneand the client understandstheprocedure. Contr
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ast dye is notused, so shellfish/iodine allergiesarenot related. The client will notbe radioactiv
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eanddoes notneedradiationprecautions.Sedationis notusedinthisprocedure.
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, While takingaclienthistory, whichfactor(s)that placetheclientatriskAforahematologichealth pr
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oblem willthenursedocument? (Select all that apply.)
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a. Familyhistoryofbleeding problems cn




b. Dietlowiniron and protein
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c. Excessivealcoholconsumption n
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d. Familyhistoryof allergies cn




e. Diethighinsaturatedfats n
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f. DiethighinVitaminK -correctanswersANS:A,C,F n
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Afamilyhistory of bleeding problems places the client at riskforhaving asimilarproblem. Exce
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ssive alcohol can damage theliverwhereprothrombin is produced. Adiet high in Vitamin K ca
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n causeexcessive clottingbecause it isamajor clottingfactor.
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Anolderclientasksthenursewhy"peoplemyage" haveweaker immunesystemsthan younger pe
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ople. What responses bythenurse arebest?(Select allthat apply.)
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a. "Bonemarrowproduces fewerblood cells asyou age." q c n cn cn cn




b. "Youmayhavedecreasedlevelsofcirculating platelets." q cn
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c. "Youhavelowerlevelsofplasmaproteinsintheblood."
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d. "Lymphocytesbecomemorereactiveto antigens." c n




e. "Spleenfunctiondeclinesafterage60."-correctanswersANS:A,C n
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The aging adulthas bonemarrowthat produces fewercells anddecreased blood volume wi th fewe
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rplasmaproteins.Plateletnumbersremainunchanged,lymphocytesbecomeless reactive, and spl n
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een function stays thesame.
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Thenurseisassessing aclient experiencinganemia.Whichlaboratoryfindingswillthenurse expe
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ct for this client? (Select all that apply.)
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a. Increasedhematocrit n
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b. Decreasedredbloodcellcount n
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c. Decreased serum iron cn cn




d. Decreased hemoglobin cn




e. Increasedplateletcount