Chapter 41: Assessment of Hematologic System (NCLEX Practice Questions) – Flashcards
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The nurse is performing an admission assessment on a 46-year-old client, who states, "I have been drinking a 12-pack of beer every day for the past 20 years." Which laboratory abnormality does the nurse correlate with this history? a. Decreased bleeding time b. Elevated red blood cell (RBC) count c. Decreased white blood cell (WBC) count d. Elevated prothrombin time (PT)
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ANS: D The liver is the site for production of prothrombin and most of the blood-clotting factors. If the liver is damaged because of chronic alcoholism, it is unable to produce these clotting factors. Therefore, the PT could become elevated, which would reflect deficiency of some clotting factors. The WBC would not be elevated in this situation because no infection is present. Bleeding time would likely increase. The client's RBC count most likely would not be affected unless the client was bleeding, in which case it would decrease.
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The nurse is administering a prescribed fibrinolytic to a client who is having a myocardial infarction (MI). Which adverse effect does the nurse monitor for? a. Orthostatic hypotension b. Bleeding c. Nausea and vomiting d. Deep vein thrombosis
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ANS: B A fibrinolytic lyses any clots in the body, thus causing an increased risk for bleeding. Fibrinolytic therapy does not place the client at risk for hypotension, thrombosis, or nausea and vomiting.
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The nurse is caring for a client who has an elevated white blood cell count. Which intervention does the nurse implement for this client? a. Administer the prescribed Tylenol. b. Obtain the client's temperature. c. Hold the client's prescribed steroids. d. Assess the client's respiratory rate.
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ANS: B White blood cells provide immunity and protect against invasion and infection. An elevated white blood cell count could indicate an infectious process, which could cause an elevation in body temperature. Tylenol would treat a fever but not the elevated white blood cell count. Steroids place the client at higher risk for infection but should not be stopped suddenly. The respiratory rate does not need to be assessed in this client.
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The nurse is assessing a client's susceptibility to rejecting a transplanted kidney. Which result does the nurse recognize as increasing the client's chances of rejection? a. Decreased white blood cell count b. Decreased T-lymphocyte helper c. Increased neutrophil count d. Increased cytotoxic-cytolytic T cell
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ANS: D Cytotoxic-cytolytic T cells function to attack and destroy non-self-cells, specifically virally infected cells and cells from transplanted grafts and organs. A high level of these cells would increase the chances of rejection. Decreased white blood cells would indicate immune suppression. Neutrophils are increased during an infection.
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A client who has a chronic vitamin B12 deficiency is admitted to the hospital. When obtaining the client's health history, which priority question does the nurse ask this client? a. "Are you having blood in your stools?" b. "Do you bruise easily?" c. "Do you notice any changes in your memory?" d. "Are you having any pain?"
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ANS: C Vitamin B12 deficiency impairs cerebral, olfactory, spinal cord, and peripheral nerve function. Severe chronic deficiency may cause permanent neurologic degeneration. The other options are not symptoms of vitamin B12 deficiency.
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The nurse is caring for four clients with hematologic-type problems. Which client does the nurse prioritize to see first? a. 60-year-old female with decreased erythropoietin b. 18-year-old female with decreased protein levels c. 82-year-old male with an increased thromboxane level d. 36-year-old male with increased lymphocytes
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ANS: A The kidney releases more erythropoietin when tissue oxygenation levels are low. This growth factor then stimulates the bone marrow to increase red blood cell (RBC) production, which improves tissue oxygenation and prevents hypoxia. Hypoxia causes the body to increase its respiratory rate to overcome decreased oxygenation of the tissues. All these clients are important, but the woman with decreased erythropoietin takes priority because of her risk for hypoxia.
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The nurse is caring for a client who is receiving heparin therapy. How does the nurse evaluate the therapeutic effect of the therapy? a. Monitor the partial thromboplastin time (PTT). b. Monitor fibrin degradation products. c. Assess bleeding time. d. Evaluate platelets.
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ANS: A The PTT assesses the intrinsic clotting cascade. Heparin therapy is monitored by the PTT. Platelets are monitored by the platelet count laboratory value, bleeding time evaluates vascular and platelet activity during hemostasis, and fibrin degradation products help assess for fibrinolysis.
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The nurse is planning discharge teaching for a client who has a splenectomy. Which statement does the nurse include in this client's teaching plan? a. "Do not eat raw fruits or vegetables." b. "Avoid environmental allergens." c. "Avoid crowds and people who are sick." d. "Do not play contact sports."
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ANS: C The spleen is the major site of B-lymphocyte maturation and antibody production. Those who undergo splenectomies for any reason have a decreased antibody-mediated immune response and are particularly susceptible to viral infections. Eating raw fruits and vegetables places the client at risk for bacterial infections. The body responds to environmental allergens with an unspecific inflammatory process. The client is not at risk for bleeding or injury due to contact sports.
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The nurse observes yellow-tinged sclera in a client with dark skin. Based on this assessment finding, what does the nurse do next? a. Inspect the client's hard palate. b. Examine the soles of the client's feet. c. Assess the client's pulses. d. Auscultate the client's lung sounds.
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ANS: A Jaundice can best be observed in clients with dark skin by inspecting the oral mucosa, especially the hard palate, for yellow discoloration. Because sclera may have subconjunctival fat deposits that show a yellow hue, and because foot calluses may appear yellow, neither of these areas should be used to assess for jaundice. The client's pulse and lung sounds have no correlation with an assessment of jaundice.
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The nurse is assessing a 75-year-old male client. Which blood value indicates that the client is experiencing normal changes associated with aging? a. White blood cell (WBC) count, 5000/mm3 b. Platelet count, 100,000/mm3 c. Hemoglobin, 13.0 g/dL d. Prothrombin time (PT), 14 seconds
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ANS: C Hemoglobin levels in men and women fall after middle age. Therefore, this client's hemoglobin value would be considered part of the aging process. Platelet counts and blood-clotting times are not age related; the client's platelet count and PT are elevated for some other reason. The WBC count shown is normal.
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The nurse is caring for a client who has a decreased serum iron level. Which intervention does the nurse prioritize for this client? a. Family assessment b. Cardiac assessment c. Administration of vitamin K d. Dietary consult
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ANS: D Diets can alter cell quality and affect blood clotting. Diets low in iron can cause anemia and decrease the function of all red blood cells. The question does not say that the hemoglobin is low enough to affect the cardiac function. Family assessment may be important in finding out any genetic or family lifestyle causes of the low serum iron level. However, the first intervention that the nurse can provide is to have the client's dietary habits evaluated and changed so that iron levels can increase. Vitamin K is involved with clotting, not with iron stores.
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The nurse is monitoring a client with liver failure. Which assessments does the nurse perform when monitoring for bleeding in this client? (Select all that apply.) a. Stool b. Hair c. Urine d. Gums e. Lung sounds
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ANS: A, C, D The liver is the site for production of clotting factors. Without these factors, the client is at risk for bleeding. Common areas of bleeding include the gums and mucous membranes, bladder, and gastrointestinal tract. Lung sounds and hair are part of the assessment but are not essential in the presence of liver failure and hematologic abnormalities.
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The nurse helps to ambulate a client who has anemia. Which clinical manifestation indicates that the client is not tolerating the activity? a. Pulse oximetry reading of 95% b. Respiratory rate of 20 breaths/min c. Heart rate of 110 beats/min d. Blood pressure of 120/90 mm Hg
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ANS: C The red blood cells contain thousands of hemoglobin molecules. The most important feature of hemoglobin is its ability to combine loosely with oxygen. A low hemoglobin level can cause decreased oxygenation to the tissues, thus causing a compensatory increase in heart rate. The other options are close to normal range and are not indicative of not tolerating this activity.
