NUR 504 ADVANCED HEALTH ASSESSMENT EXAM 3 2024
QUESTIONS AND ANSWERS
The nurse is assessing an older client for any potential hematologic health problem. Which assessment
finding is the most significant and would be reported to the primary health care provider?
a. Poor skin turgor on both forearms
b. Multiple petechiae and large bruises
c. Dry, flaky skin on arms and legs
d. Decreased body hair distribution
ANS: B
The presence of multiple petechiae and large bruises indicate a possible problem with blood
clotting. Older adults typically have poor skin turgor and dry, flaky skin due to decreased
body fluid as a result of aging. They also lose body hair or have thinning hair as a normal
change of aging.
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.
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.
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.
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.
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.
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)
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.
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.
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.
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.)
QUESTIONS AND ANSWERS
The nurse is assessing an older client for any potential hematologic health problem. Which assessment
finding is the most significant and would be reported to the primary health care provider?
a. Poor skin turgor on both forearms
b. Multiple petechiae and large bruises
c. Dry, flaky skin on arms and legs
d. Decreased body hair distribution
ANS: B
The presence of multiple petechiae and large bruises indicate a possible problem with blood
clotting. Older adults typically have poor skin turgor and dry, flaky skin due to decreased
body fluid as a result of aging. They also lose body hair or have thinning hair as a normal
change of aging.
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.
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.
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.
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.
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.
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)
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.
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.
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.
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.)
