NUR 504 EXAM 2 PREP NEWEST 2026/2027
ACTUAL EXAM COMPLETE EXAM QUESTIONS
AND CORRECT VERIFIED ANSWERS WITH
RATIONALE
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. –
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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
(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.
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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.
- 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.
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d. Tell the client that he or she will be asleep. - Correct Answer :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.
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
f. Diet high in Vitamin K - Correct Answer :ANS: A, C, F
A family history of bleeding problems places the client at risk for having a similar problem.
Excessive alcohol can damage the liver where prothrombin is produced. A diet high in
Vitamin K can cause excessive clotting because it is a major clotting factor.
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