NUR 504 EXAM 3 QUESTIONS WITH CORRECT ANSWERS
Thenurseisassessing anolderclientforanypotentialhematologichealthproblem.Whicha ssess
n
c n
c c n
q n
c n
c n
c n
c n
c n
c n
c n
c cn
ment finding is the most significant and would bereported to theprimaryhealth care provide
c n
q q c n cn cn c n
q cn cn cn cn cn cn cn
r?
a. Poorskinturgoronbothforearms n
c n
c n
c n
c
b. Multiplepetechiaeandlargebruises n
c n
c
c. Dry,flakyskinonarms andlegs
n
c n
c n
c cn
q n
c
d. Decreasedbodyhairdistribution -correctanswersANS:B n
c cn n
c n
c
Thepresenceof multiplepetechiae and largebruises indicateapossibleproblem withblood clott
n
c cn cn c n
q cn cn
ing. Older adults typically havepoorskin turgor and dry, flakyskin duetodecreased body fluid as
cn cn c n
q cn cn cn cn cn cn cn cn cn
aresult of aging. They also losebodyhairorhavethinning hairasanormal change of aging.
cn cn cn cn cn c n
q cn cn cn
Anurseisassessing a dark- n
c n
c c n
q cn
skinnedclient forpallor.Whatnursingassessment isbesttoassess forpallor inthis client?
cn
q n
c cn
q n
c n
c cn
q cn n
c cn
q
a. Assesstheconjunctivaoftheeye. n
c n
c n
c
b. Have the patientopen the hand widely. c n
q cn
c. Lookat theroofofthepatient'smouth. cn n
c n
c n
c n
c
d. Palpateforareasofmildswelling.-correctanswersANS:A n
c n
c n
c n
c n
c n
c n
c
Toassesspallorindark-
n
c n
c n
c
skinned people,assesstheconjunctivaoftheeyeorthemucous membranes.Lookingattheroofof
cn n
c n
c n
c cn n
c n
c n
c n
c n
c
themouthcanrevealjaundice.Openingthehandwidelyis not relatedtopallor,norispalpatingfor
n
c n
c n
c n
c n
c n
c n
c n
c cn cn
q n
c n
c
mild swelling. cn
Ahospitalized clienthasaplateletcountof 58,000/mm3 (58 cn n
c n
c cn cn n
c
×109/L).What actionbythenurseismost appropriate?
n
c n
c qcn n
c n
c n
c q cn
a. Encouragehigh-proteinfoods.
b. Instituteneutropenicprecautions.
c. Limitvisitorstohealthyadults. n
c n
c n
c n
c
d. Placetheclient onsafetyprecautions.-correct answersANS:D
n
c cn
q n
c n
c n
c cn
q n
c
,With aplateletcountbetween 40,000 and 80,000/mm3
cn cn cn cn
(40 and 80 × 109 /L), clients areat risk of prolonged bleeding even after minor trauma. Thenurse
cn cn cn cn cn cn c n
q cn c n
q cn cn c n
q cn cn cn cn cn
wouldplacethe client on safetyorbleedingprecautions asthe most appropriate actio n
c cn
q cn n
c cn
q cn cn
q cn
n.High- n
c
protein foods, while healthy, are not the priority. Neutropenic precautions are not needed a s th
cn cn cn cn cn cn cn cn c n
q c n
q cn cn cn cn cn
e patient's white blood cell count is not low. Limiting visitors would also be more likely r elated
cn cn cn cn cn cn cn cn cn cn cn cn cn cn cn cn cn
toalowwhite blood cell count.
cn cn cn cn
A client is having a bone marrow aspiration and biopsy. What action by the nurse takes
cn q c n cn c n
q cn cn cn cn cn cn c n
q cn cn cn cn cn
priority?
a. Administerpainmedication first. cn
b. Ensurethatvalidconsentisinthemedicalrecord. n
c n
c n
c n
c n
c n
c n
c n
c
c. Havetheclientshowerinthemorning. n
c n
c n
c n
c
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
cn cn cn cn cn cn cn cn cn cn cn
iority.The client mayormaynot need orbe able toshower.
n
c cn
q c n
q cn n
c cn cn
What is thenurse's priority when caring for aclient who just completed abonemarrow aspi ra
cn cn cn cn cn qc n c n
q cn c n
q cn cn cn
tion andbiopsy? n
c n
c
a. Teachtheclientto avoidactivityfor 24 to48hourstopreventinfection. n
c cn cn cn
b. Administeranonsteroidalanti-inflammatorydrug(NSAID)topromotecomfort. n
c
c. Checkthepressuredressing frequentlyforsignsofexcessiveoractivebleeding. n
c q cn n
c n
c
d. Reportthelaboratoryresultstotheprimaryhealthcareprovider.-
qw nc n
c
correctanswersANS:C Theclienthaving abonemarrowaspiration and biopsyhas apuncture n
c cn cn n
c cn cn cn
q
woundfrom the larg e needleused toextractthebonemarrow.Therefore,theclientisatrisk fo
cn c n
q cn n
c n
c n
c n
c n
c q cn
rbleeding.ANSAID should not be given because it can cause bleeding. Avoiding activityhelps
n
c cn cn q c n cn cn cn cn
q cn cn cn cn cn
toprevent bleeding,notinfection,and reportingthe results ofthebiopsyisnot theresponsibil
cn n
c n
c n
c cn c n
q n
c n
c n
c q cn
ityofthe n
c n
c n
c
,nurse.
Anurseiscaring forfourclients.Afterreviewing today'slaboratoryresults,which client wou ld th
n
c cn
q n
c qcn n
c cn q cn cn cn
enurseassessfirst? n
c n
c
a. Clientwithaninternationalnormalizedratioof2.8 n
c n
c n
c n
c n
c
b. Clientwitha platelet countof128,000/mm3 (128×109/L).
n
c n
c c n
q n
c n
c cn n
c n
c
c. Clientwithaprothrombin time(PT)of28seconds
n
c n
c cn n
c n
c n
c
d. Clientwithared blood cellcountof 5.1 million/mcL(5.1×1012/L)-
n
c n
c n
c cn cn n
c n
c cn c n
q n
c n
c n
c n
c
correctanswersA normalPTis11 to12.5seconds.Thisclient is at highrisk ofbleeding withaPT
n
c q cn n
c n
c n
c q cn n
c n
c n
c n
c q cn q cn q cn n
c cn
q n
c cn
q n
c n
c cn
of 28 seconds. Theother values arewithin normal limits.
cn cn cn cn cn cn cn
Aclientishaving abonemarrowaspiration andbiopsyandisextremelyanxious.Whataction byth
n
c n
c qc n n
c cn n
c n
c n
c n
c n
c n
c cn
enurse is the most appropriate?
cn cn cn c n
q
a. Assesstheclient'sfearsandcopingmechanisms. n
c n
c n
c n
c
b. Reassuretheclientthat thisis acommon test. n
c qcn n
c cn cn
c. Sedate the client prior totheprocedure. c n
q cn
d. Telltheclientthatheorshewillbeasleep.-correctanswersANS: A
n
c n
c n
c n
c n
c n
c n
c n
c cn
Assessingtheclient'sspecific fearsandcopingmechanismshelpsguidethenurseinproviding holi
n
c n
c c n
q n
c n
c n
c n
c n
c n
c n
c cn
sticcarethatbestmeetsthe client's needs.Reassurance willbehelpfulbut is notthebest option.
n
c cn
q n
c cn cn
q cn c n
q cn
Sedation is usually used. The client mayormaynot betotallyasleepduringthe procedure.
cn cn cn cn c n
q cn cn
Aclientishaving aradioisotopic imaging scan.What actionbythenurseismostimportant?
n
c n
c q c n n
c c n
q cn
q n
c q cn n
c n
c n
c n
c
a. Assesstheclientforshellfish allergies. n
c n
c cn
b. Placethe client onradiation precautions.
n
c qcn n
c cn
c. Sedatetheclientbefore thescan. n
c
d. Teachthe clientabout theprocedure.- correctanswersANS:D n
c cn
q cn
Thenurse should ensure that teaching is doneand the client understandstheprocedure. Contr
cn cn cn cn cn cn cn c n
q cn
ast dye is notused, so shellfish/iodine allergiesarenot related. The client will notbe radioactiv
cn cn q c n cn cn cn cn cn c n
q cn cn
eanddoes notneedradiationprecautions.Sedationis notusedinthisprocedure.
n
c n
c cn
q n
c n
c n
c n
c q cn n
c n
c
, While takingaclienthistory, whichfactor(s)that placetheclientatriskAforahematologichealth pr
cn n
c cn cn n
c n
c cn
oblem willthenursedocument? (Select all that apply.)
cn cn c n
q cn cn
a. Familyhistoryofbleeding problems cn
b. Dietlowiniron and protein
n
c n
c n
c cn cn
c. Excessivealcoholconsumption n
c
d. Familyhistoryof allergies cn
e. Diethighinsaturatedfats n
c n
c n
c
f. DiethighinVitaminK -correctanswersANS:A,C,F n
c n
c n
c cn
q n
c n
c n
c n
c n
c
Afamilyhistory of bleeding problems places the client at riskforhaving asimilarproblem. Exce
cn cn cn cn c n
q c n
q cn cn cn
ssive alcohol can damage theliverwhereprothrombin is produced. Adiet high in Vitamin K ca
cn cn cn cn cn cn cn cn cn cn cn cn
q
n causeexcessive clottingbecause it isamajor clottingfactor.
cn n
c c n
q n
c cn cn
q n
c cn n
c
Anolderclientasksthenursewhy"peoplemyage" haveweaker immunesystemsthan younger pe
n
c n
c n
c cn cn n
c cn cn
ople. What responses bythenurse arebest?(Select allthat apply.)
cn c n
q cn c n
q
a. "Bonemarrowproduces fewerblood cells asyou age." q c n cn cn cn
b. "Youmayhavedecreasedlevelsofcirculating platelets." q cn
q
c. "Youhavelowerlevelsofplasmaproteinsintheblood."
n
c n
c n
c n
c n
c
d. "Lymphocytesbecomemorereactiveto antigens." c n
e. "Spleenfunctiondeclinesafterage60."-correctanswersANS:A,C n
c n
c n
c n
c n
c n
c n
c n
c
The aging adulthas bonemarrowthat produces fewercells anddecreased blood volume wi th fewe
cn cn cn n
c q c n cn cn n
c cn cn cn cn cn
rplasmaproteins.Plateletnumbersremainunchanged,lymphocytesbecomeless reactive, and spl n
c n
c c n
q cn cn
een function stays thesame.
cn cn cn
Thenurseisassessing aclient experiencinganemia.Whichlaboratoryfindingswillthenurse expe
n
c n
c c n
q cn
q n
c n
c n
c n
c n
c n
c n
c cn
ct for this client? (Select all that apply.)
cn cn cn cn c n
q cn cn
a. Increasedhematocrit n
c
b. Decreasedredbloodcellcount n
c n
c n
c
c. Decreased serum iron cn cn
d. Decreased hemoglobin cn
e. Increasedplateletcount
Thenurseisassessing anolderclientforanypotentialhematologichealthproblem.Whicha ssess
n
c n
c c n
q n
c n
c n
c n
c n
c n
c n
c n
c cn
ment finding is the most significant and would bereported to theprimaryhealth care provide
c n
q q c n cn cn c n
q cn cn cn cn cn cn cn
r?
a. Poorskinturgoronbothforearms n
c n
c n
c n
c
b. Multiplepetechiaeandlargebruises n
c n
c
c. Dry,flakyskinonarms andlegs
n
c n
c n
c cn
q n
c
d. Decreasedbodyhairdistribution -correctanswersANS:B n
c cn n
c n
c
Thepresenceof multiplepetechiae and largebruises indicateapossibleproblem withblood clott
n
c cn cn c n
q cn cn
ing. Older adults typically havepoorskin turgor and dry, flakyskin duetodecreased body fluid as
cn cn c n
q cn cn cn cn cn cn cn cn cn
aresult of aging. They also losebodyhairorhavethinning hairasanormal change of aging.
cn cn cn cn cn c n
q cn cn cn
Anurseisassessing a dark- n
c n
c c n
q cn
skinnedclient forpallor.Whatnursingassessment isbesttoassess forpallor inthis client?
cn
q n
c cn
q n
c n
c cn
q cn n
c cn
q
a. Assesstheconjunctivaoftheeye. n
c n
c n
c
b. Have the patientopen the hand widely. c n
q cn
c. Lookat theroofofthepatient'smouth. cn n
c n
c n
c n
c
d. Palpateforareasofmildswelling.-correctanswersANS:A n
c n
c n
c n
c n
c n
c n
c
Toassesspallorindark-
n
c n
c n
c
skinned people,assesstheconjunctivaoftheeyeorthemucous membranes.Lookingattheroofof
cn n
c n
c n
c cn n
c n
c n
c n
c n
c
themouthcanrevealjaundice.Openingthehandwidelyis not relatedtopallor,norispalpatingfor
n
c n
c n
c n
c n
c n
c n
c n
c cn cn
q n
c n
c
mild swelling. cn
Ahospitalized clienthasaplateletcountof 58,000/mm3 (58 cn n
c n
c cn cn n
c
×109/L).What actionbythenurseismost appropriate?
n
c n
c qcn n
c n
c n
c q cn
a. Encouragehigh-proteinfoods.
b. Instituteneutropenicprecautions.
c. Limitvisitorstohealthyadults. n
c n
c n
c n
c
d. Placetheclient onsafetyprecautions.-correct answersANS:D
n
c cn
q n
c n
c n
c cn
q n
c
,With aplateletcountbetween 40,000 and 80,000/mm3
cn cn cn cn
(40 and 80 × 109 /L), clients areat risk of prolonged bleeding even after minor trauma. Thenurse
cn cn cn cn cn cn c n
q cn c n
q cn cn c n
q cn cn cn cn cn
wouldplacethe client on safetyorbleedingprecautions asthe most appropriate actio n
c cn
q cn n
c cn
q cn cn
q cn
n.High- n
c
protein foods, while healthy, are not the priority. Neutropenic precautions are not needed a s th
cn cn cn cn cn cn cn cn c n
q c n
q cn cn cn cn cn
e patient's white blood cell count is not low. Limiting visitors would also be more likely r elated
cn cn cn cn cn cn cn cn cn cn cn cn cn cn cn cn cn
toalowwhite blood cell count.
cn cn cn cn
A client is having a bone marrow aspiration and biopsy. What action by the nurse takes
cn q c n cn c n
q cn cn cn cn cn cn c n
q cn cn cn cn cn
priority?
a. Administerpainmedication first. cn
b. Ensurethatvalidconsentisinthemedicalrecord. n
c n
c n
c n
c n
c n
c n
c n
c
c. Havetheclientshowerinthemorning. n
c n
c n
c n
c
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
cn cn cn cn cn cn cn cn cn cn cn
iority.The client mayormaynot need orbe able toshower.
n
c cn
q c n
q cn n
c cn cn
What is thenurse's priority when caring for aclient who just completed abonemarrow aspi ra
cn cn cn cn cn qc n c n
q cn c n
q cn cn cn
tion andbiopsy? n
c n
c
a. Teachtheclientto avoidactivityfor 24 to48hourstopreventinfection. n
c cn cn cn
b. Administeranonsteroidalanti-inflammatorydrug(NSAID)topromotecomfort. n
c
c. Checkthepressuredressing frequentlyforsignsofexcessiveoractivebleeding. n
c q cn n
c n
c
d. Reportthelaboratoryresultstotheprimaryhealthcareprovider.-
qw nc n
c
correctanswersANS:C Theclienthaving abonemarrowaspiration and biopsyhas apuncture n
c cn cn n
c cn cn cn
q
woundfrom the larg e needleused toextractthebonemarrow.Therefore,theclientisatrisk fo
cn c n
q cn n
c n
c n
c n
c n
c q cn
rbleeding.ANSAID should not be given because it can cause bleeding. Avoiding activityhelps
n
c cn cn q c n cn cn cn cn
q cn cn cn cn cn
toprevent bleeding,notinfection,and reportingthe results ofthebiopsyisnot theresponsibil
cn n
c n
c n
c cn c n
q n
c n
c n
c q cn
ityofthe n
c n
c n
c
,nurse.
Anurseiscaring forfourclients.Afterreviewing today'slaboratoryresults,which client wou ld th
n
c cn
q n
c qcn n
c cn q cn cn cn
enurseassessfirst? n
c n
c
a. Clientwithaninternationalnormalizedratioof2.8 n
c n
c n
c n
c n
c
b. Clientwitha platelet countof128,000/mm3 (128×109/L).
n
c n
c c n
q n
c n
c cn n
c n
c
c. Clientwithaprothrombin time(PT)of28seconds
n
c n
c cn n
c n
c n
c
d. Clientwithared blood cellcountof 5.1 million/mcL(5.1×1012/L)-
n
c n
c n
c cn cn n
c n
c cn c n
q n
c n
c n
c n
c
correctanswersA normalPTis11 to12.5seconds.Thisclient is at highrisk ofbleeding withaPT
n
c q cn n
c n
c n
c q cn n
c n
c n
c n
c q cn q cn q cn n
c cn
q n
c cn
q n
c n
c cn
of 28 seconds. Theother values arewithin normal limits.
cn cn cn cn cn cn cn
Aclientishaving abonemarrowaspiration andbiopsyandisextremelyanxious.Whataction byth
n
c n
c qc n n
c cn n
c n
c n
c n
c n
c n
c cn
enurse is the most appropriate?
cn cn cn c n
q
a. Assesstheclient'sfearsandcopingmechanisms. n
c n
c n
c n
c
b. Reassuretheclientthat thisis acommon test. n
c qcn n
c cn cn
c. Sedate the client prior totheprocedure. c n
q cn
d. Telltheclientthatheorshewillbeasleep.-correctanswersANS: A
n
c n
c n
c n
c n
c n
c n
c n
c cn
Assessingtheclient'sspecific fearsandcopingmechanismshelpsguidethenurseinproviding holi
n
c n
c c n
q n
c n
c n
c n
c n
c n
c n
c cn
sticcarethatbestmeetsthe client's needs.Reassurance willbehelpfulbut is notthebest option.
n
c cn
q n
c cn cn
q cn c n
q cn
Sedation is usually used. The client mayormaynot betotallyasleepduringthe procedure.
cn cn cn cn c n
q cn cn
Aclientishaving aradioisotopic imaging scan.What actionbythenurseismostimportant?
n
c n
c q c n n
c c n
q cn
q n
c q cn n
c n
c n
c n
c
a. Assesstheclientforshellfish allergies. n
c n
c cn
b. Placethe client onradiation precautions.
n
c qcn n
c cn
c. Sedatetheclientbefore thescan. n
c
d. Teachthe clientabout theprocedure.- correctanswersANS:D n
c cn
q cn
Thenurse should ensure that teaching is doneand the client understandstheprocedure. Contr
cn cn cn cn cn cn cn c n
q cn
ast dye is notused, so shellfish/iodine allergiesarenot related. The client will notbe radioactiv
cn cn q c n cn cn cn cn cn c n
q cn cn
eanddoes notneedradiationprecautions.Sedationis notusedinthisprocedure.
n
c n
c cn
q n
c n
c n
c n
c q cn n
c n
c
, While takingaclienthistory, whichfactor(s)that placetheclientatriskAforahematologichealth pr
cn n
c cn cn n
c n
c cn
oblem willthenursedocument? (Select all that apply.)
cn cn c n
q cn cn
a. Familyhistoryofbleeding problems cn
b. Dietlowiniron and protein
n
c n
c n
c cn cn
c. Excessivealcoholconsumption n
c
d. Familyhistoryof allergies cn
e. Diethighinsaturatedfats n
c n
c n
c
f. DiethighinVitaminK -correctanswersANS:A,C,F n
c n
c n
c cn
q n
c n
c n
c n
c n
c
Afamilyhistory of bleeding problems places the client at riskforhaving asimilarproblem. Exce
cn cn cn cn c n
q c n
q cn cn cn
ssive alcohol can damage theliverwhereprothrombin is produced. Adiet high in Vitamin K ca
cn cn cn cn cn cn cn cn cn cn cn cn
q
n causeexcessive clottingbecause it isamajor clottingfactor.
cn n
c c n
q n
c cn cn
q n
c cn n
c
Anolderclientasksthenursewhy"peoplemyage" haveweaker immunesystemsthan younger pe
n
c n
c n
c cn cn n
c cn cn
ople. What responses bythenurse arebest?(Select allthat apply.)
cn c n
q cn c n
q
a. "Bonemarrowproduces fewerblood cells asyou age." q c n cn cn cn
b. "Youmayhavedecreasedlevelsofcirculating platelets." q cn
q
c. "Youhavelowerlevelsofplasmaproteinsintheblood."
n
c n
c n
c n
c n
c
d. "Lymphocytesbecomemorereactiveto antigens." c n
e. "Spleenfunctiondeclinesafterage60."-correctanswersANS:A,C n
c n
c n
c n
c n
c n
c n
c n
c
The aging adulthas bonemarrowthat produces fewercells anddecreased blood volume wi th fewe
cn cn cn n
c q c n cn cn n
c cn cn cn cn cn
rplasmaproteins.Plateletnumbersremainunchanged,lymphocytesbecomeless reactive, and spl n
c n
c c n
q cn cn
een function stays thesame.
cn cn cn
Thenurseisassessing aclient experiencinganemia.Whichlaboratoryfindingswillthenurse expe
n
c n
c c n
q cn
q n
c n
c n
c n
c n
c n
c n
c cn
ct for this client? (Select all that apply.)
cn cn cn cn c n
q cn cn
a. Increasedhematocrit n
c
b. Decreasedredbloodcellcount n
c n
c n
c
c. Decreased serum iron cn cn
d. Decreased hemoglobin cn
e. Increasedplateletcount
