Unit 8 - Chapter 33: Assessment of the Hematologic System Ignatavicius: Medical-Surgical Nursing, 11th Edition

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 x 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 x 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 x 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 x 1012/L)

ANS: C

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.)

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

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.

An older client asks the nurse why "people my age" have weaker immune systems than younger people. What responses by the nurse are best? (Select all that apply.)

a. "Bone marrow produces fewer blood cells as you age."

b. "You may have decreased levels of circulating platelets."

c. "You have lower levels of plasma proteins in the blood."

d. "Lymphocytes become more reactive to antigens."

e. "Spleen function declines after age 60."

ANS: A, C

The aging adult has bone marrow that produces fewer cells and decreased blood volume with

fewer plasma proteins. Platelet numbers remain unchanged, lymphocytes become less

reactive, and spleen function stays the same.

The nurse is assessing a client experiencing anemia. Which laboratory findings will the nurse

expect for this client? (Select all that apply.)

a. Increased hematocrit

b. Decreased red blood cell count

c. Decreased serum iron

d. Decreased hemoglobin

e. Increased platelet count

f. Decreased white blood cell count

ANS: B, C, D

Clients experiencing anemia have a decreased red blood cell count which leads to a decreased

hemoglobin and hematocrit. For some clients, serum iron levels are also decreased. Anemia is

not a problem involving platelets or white blood cells.

A nurse works in a gerontology clinic. What age-related change(s) related to the hematologic

system will the nurse expect during health assessment? (Select all that apply.)

a. Dentition deteriorates with more cavities.

b. Nail beds may be thickened or discolored.

c. Progressive loss or thinning of hair occurs.

d. Sclerae begin to turn yellow or pale.

e. Skin becomes more oily.

ANS: B, C

Common findings in older adults include thickened or discolored nail beds, dry (not oily) skin, and thinning hair. The nurse adapts to these changes by altering assessment techniques.

Having more dental caries and changes in the sclerae are not normal age-related changes.