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Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 30: Nursing Assessment: "est #an$


M%L"&'LE C (&CE 1. When doing discharge teaching for a patient who has had an emergency splenectomy

ematologic S!stem

following an automobile accident, the nurse will teach the patient about the increased risk for a infection.
. b lymphedema. . c chronic anemia. . d prolonged bleeding. .

ANS: A

Splenectomy increases the risk for infection, especially with gram-positi e bacteria. !he risks for lymphedema, bleeding, and anemia are not increased after splenectomy.
"#$: %ogniti e &e el: Application !,-: Nursing -rocess: #mplementation '($: )*+ .S%: N%&(/: -hysiological #ntegrity

0. While obtaining a health history from a patient with numerous petechiae on the skin, the

nurse asks the patient specifically about the patient1s use of a salicylates.
. b contracepti es. . c antisei2ure drugs. . d antihypertensi es. .

ANS: A

Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antisei2ure drugs may cause anemia, but not bleeding. ,ral contracepti es increase clotting risk. Antihypertensi es do not commonly cause problems with decreased clotting.
"#$: %ogniti e &e el: %omprehension !,-: Nursing -rocess: Assessment '($: )*3 .S%: N%&(/: -hysiological #ntegrity

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6. !he nurse who is re iewing laboratory data for an 7)-year-old patient will be most

concerned about a a white blood cell 8W9%: count of 6;55<&.


. b a hematocrit of 6+=. . c a platelet count of *55,555<&. . d a hemoglobin of 11.7 g<d&. .

ANS: A

!he total W9% count is not usually affected by aging, and the low W9% here would indicate that the patient1s immune function may be compromised. !he platelet count is normal. !he slight decrease in hemoglobin and hematocrit are not unusual for an older patient.
"#$: %ogniti e &e el: Application !,-: Nursing -rocess: Assessment '($: )*7 .S%: N%&(/: -hysiological #ntegrity

*. !he health care pro ider performs a bone marrow aspiration from the left posterior iliac

crest on a patient with pancytopenia. $ollowing the procedure, the nurse should a ele ate the head of the bed to *; degrees.
. b apply a sterile 9and-Aid at the aspiration site. . c use half-inch sterile gau2e to pack the wound. . d ha e the patient lie on the left side for an hour. .

ANS: "

!o decrease the risk for bleeding, the patient should lie on the left side for 65 to )5 minutes. !he wound after bone marrow biopsy is small and will not be packed with gau2e. A pressure dressing is used to co er the aspiration site. !here is no indication that the head needs to be ele ated for this patient.
"#$: %ogniti e &e el: Application !,-: Nursing -rocess: #mplementation '($: );7 .S%: N%&(/: -hysiological #ntegrity

;. When caring for a patient with a chronic iron deficiency anemia, the nurse will assess for a yellow-tinged sclerae. . b shiny, smooth tongue. . c numbness of the e>tremities. .

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d gum bleeding and tenderness. .

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ANS: 9

&oss of the papillae of the tongue occurs with chronic iron deficiency. Scleral ?aundice is associated with hemolysis, gum bleeding and tenderness occur with thrombocytopenia or neutropenia, and e>tremity numbness is associated with itamin 910 deficiency or pernicious anemia.
"#$: %ogniti e &e el: Application !,-: Nursing -rocess: Assessment '($: );0-);6 .S%: N%&(/: -hysiological #ntegrity

). A patient1s complete blood count shows a hemoglobin of 05 g<d& and a hematocrit of

;*=. Which @uestion should the nurse ask to determine possible causes of this findingA a BCas there been any recent weight lossAD
. b B"o you ha e any history of lung diseaseAD . c BWhat is your intake of fruits and egetablesAD . d BCa e you noticed any dark or bloody stoolsAD .

ANS: 9

!he hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic lung disease. !he other @uestions will be appropriate for patients who are anemic.
"#$: %ogniti e &e el: Application !,-: Nursing -rocess: Assessment '($: );5-);1 .S%: N%&(/: -hysiological #ntegrity

+. When caring for a patient who is recei ing heparin, the nurse will monitor a prothrombin time 8-!:. . b fibrin degradation products 8$"-:. . c international normali2ed ratio 8#N':. . d acti ated partial thromboplastin time 8a-!!:. .

ANS: "

a-!! testing is used to determine whether heparin is at a therapeutic le el. $"- is useful in diagnosis of problems such as disseminated intra ascular coagulation 8"#%:. -! and #N' are most commonly used to test for therapeutic le els of warfarin 8%oumadin:.

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"#$: %ogniti e &e el: %omprehension !,-: Nursing -rocess: Assessment '($: );) .S%: N%&(/: -hysiological #ntegrity

7. When e aluating the red cell indices of a patient, the nurse knows that a low mean

corpuscular olume 8.%E: indicates a hypochromic red blood cells 8'9%s:.


. b inade@uate numbers of '9%s. . c low hemoglobin in the '9%s. . d small si2e of the '9%s .

ANS: "

!he .%E is low when the '9%s are smaller than normal. #nade@uate numbers of '9%s are an indication of anemia. &ow le els of hemoglobin in the '9%s and hypochromic '9%s result in a low mean corpuscular hemoglobin 8.%C:.
"#$: %ogniti e &e el: %omprehension !,-: Nursing -rocess: Assessment '($: );; .S%: N%&(/: -hysiological #ntegrity

3. While e>amining the lymph nodes during physical assessment, the nurse would be most

concerned about a a 0-cm nontender supracla icular node.

. b a 1-cm mobile and nontender a>illary node. . c an inability to palpate any superficial lymph nodes. . d firm inguinal nodes in a patient with an infected foot. .

ANS: A

(nlarged and nontender nodes are most suggesti e of malignancy such as lymphoma. $irm nodes are an e>pected finding in an area of infection. !he superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 5.; to 1 cm and nontender.
"#$: %ogniti e &e el: Application !,-: Nursing -rocess: Assessment '($: )*3-);5 F );1 .S%: N%&(/: -hysiological #ntegrity

15. #n the patient who had an intraoperati e hemorrhage 10 hours ago, the nurse would

e>pect to find hematology results indicating a a hematocrit of *;=.


. b a hemoglobin of 16.0 g<d&.

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. c a decreased white blood cell 8W9%: count. . d an ele ated reticulocyte count. .

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ANS: "

Cemorrhage causes the release of more immature '9%s from the bone marrow into the circulation. !he hematocrit and hemoglobin le els are normal. !he W9% count is not affected by bleeding.
"#$: %ogniti e &e el: %omprehension !,-: Nursing -rocess: Assessment '($: )** .S%: N%&(/: -hysiological #ntegrity

11. !he complete blood count 8%9%: and differential indicate that a patient is neutropenic.

Which action should the nurse include in the plan of careA a A oid intramuscular in?ections.
. b (ncourage increased oral fluids. . c %heck temperature e ery * hours. . d #ncrease intake of iron-rich foods. .

ANS: %

Neutropenic patients are at high risk for infection and sepsis and should be monitored fre@uently for signs of infection. !he other actions would not address the patient1s neutropenia.
"#$: %ogniti e &e el: Application !,-: Nursing -rocess: Assessment '($: );; .S%: N%&(/: -hysiological #ntegrity

10. !he history and physical for a newly admitted patient states that the complete blood count

8%9%: shows a Bshift to the left.D !he nurse will plan to monitor the patient for a cool e>tremities.
. b pallor and weakness. . c ele ated temperature. . d low o>ygen saturation. .

ANS: %

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) !he term shift to the left indicates that the number of immature polymorphonuclear neutrophils, or bands, is ele ated and is a sign of se ere infection. !here is no indication that the patient is at risk for hypo>emia, pallor<weakness, or cool e>tremities.
"#$: %ogniti e &e el: Application -lanning .S%: N%&(/: -hysiological #ntegrity '($: );; !,-: Nursing -rocess:

16. !he health care pro ider orders an ultrasound of the spleen for a patient who has been in

a car accident. Which action should the nurse take before this procedureA a %heck for any iodine allergy.
. b #nsert a large-bore #E catheter. . c -lace the patient on N-, status. . d Assist the patient to a flat position. .

ANS: "

!he patient is placed in a flat position before splenic ultrasound. !he patient does not ha e to be N-, or ha e an #E line. No iodine-containing materials are used for ultrasound.
"#$: %ogniti e &e el: Application !,-: Nursing -rocess: #mplementation '($: );7 .S%: N%&(/: -hysiological #ntegrity

1*. A confused patient with pancytopenia of unknown origin is scheduled for the following

diagnostic tests. !he nurse should contact the patient1s family member to sign a consent form before the a A9, blood typing.
. b bone marrow biopsy. . c abdominal ultrasound. . d complete blood count 8%9%:. .

ANS: 9

9one marrow biopsy is a minor surgical procedure that re@uires the patient or guardian to sign a surgical consent form. !he other procedures do not re@uire a signed consent by the patient or family.
"#$: %ogniti e &e el: Application !,-: Nursing -rocess: #mplementation '($: );7 .S%: N%&(/: -hysiological #ntegrity

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1;. When re iewing the complete blood count 8%9%: for a patient admitted with abdominal

pain, which information will be most important for the nurse to communicate to the health care pro iderA a .onocytes *=
. b Cemoglobin 11.) g<d& . c -latelet count 1*;,555<G& . d White blood cells 8W9%s: 16,;55<G& .

ANS: "

!he ele ation in W9%s indicates that an abdominal infection may be the cause of the patient1s pain and that further diagnostic testing is needed. !he monocytes are at a normal le el. !he slight decreases in hemoglobin and platelet count also would be reported but would not re@uire any immediate action.
"#$: %ogniti e &e el: Application ,9H: Special Iuestions: -rioriti2ation .S%: N%&(/: -hysiological #ntegrity '($: );6-);) !,-: Nursing -rocess: Assessment

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