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Get faster at matching terms Terms in this set (17)A client is scheduled for a bone marrow aspiration. What does the nurse do before taking the client to the treatment room for the biopsy? Clean the biopsy site with an antiseptic or povidone-iodine (Betadine). Verify that the client has given informed consent. Verifying informed consent must be done before the procedure can be performed. A signed permit must be on the client's chart. Reviewing the client's platelet count is not imperative. The nurse is assessing an adult client's endurance in performing activities of daily living (ADLs). What question does the nurse ask the client? "Can you prepare your own meals?" "How is your energy level compared with last year?" Asking the client how his or her energy level compares with last year is an activity exercise question that correctly assesses endurance compared with self-assessment in the past. The nurse is assessing a client for hematologic function risks and seeks to determine whether there is a risk that cannot be reduced or eliminated. Which clinical health history question does the nurse ask to obtain this information? "Do you seem to have excessive bleeding or bruising?" "Does anyone in your family bleed a lot?" An accurate family history is important because many disorders that affect blood and blood clotting are inherited; genetics cannot be changed. The nurse is teaching a client about what to expect during a bone marrow biopsy. Which statement by the nurse accurately describes the procedure? "The doctor will
place a small needle in your back and will withdraw some fluid." "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." It is accurate to describe a crunching sound or scraping sensation. Proper expectations minimize the client's fear during the procedure. A very large-bore needle is used for a bone marrow biopsy, not a small needle; the puncture is made in the hip or in the sternum, not the back. A client with anemia asks, "Why am I feeling tired all the time?" How does the nurse respond? "How many hours are you sleeping at night?" "Your cells are delivering less oxygen than you need." The single most common symptom of anemia is fatigue, which occurs because oxygen delivery to cells is less than is required to meet normal oxygen needs. A client with anemia asks the nurse, "Do most people have the same number of red
blood cells?" How does the nurse respond? "The number varies with gender, age, and general health." Telling the client that the number of red blood cells (RBCs) varies with gender, age, and general health is the most educational and reasonable response to the client's question The nurse is reviewing complete blood count (CBC) data for a 76-year-old client. Which decreased value causes concern because it is not age-related? Hemoglobin level Platelet (thrombocyte) count Platelet counts do not generally change with age. Hemoglobin levels in men and women fall after middle age; iron-deficient diets may play a role in this reduction. Total RBC and WBC counts (especially lymphocyte counts) are lower in older adults. The WBC count does not rise as high in response to infection in older adults as it does in younger people. A client with a low platelet count asks why platelets are important. How does the nurse answer? "Platelets make your blood clot." "The clotting process begins with your platelets." Platelets begin the blood clotting process by forming platelet plugs, but these platelet plugs are not clots and cannot provide complete hemostasis. Platelets do not clot blood; they are a part of the clotting process or cascade of coagulation. Platelets do not prevent the blood from clotting; rather they function to help blood form clots. Platelets do not finish the clotting process, they begin it. A newly admitted client has an elevated reticulocyte count. Which disorder does the nurse suspect in this client? Aplastic anemia Hemolytic anemia An elevated reticulocyte count in an anemic client indicates that the bone marrow is responding appropriately to a decrease in the total red blood cell (RBC) mass and is prematurely destroying RBCs. Therefore, more immature RBCs are in circulation. A client on anticoagulant therapy is being discharged. Which statement indicates that the client has a correct understanding of this therapy's purpose or action? "It should prevent my blood from clotting." Anticoagulants work by interfering with one or more steps involved in the blood clotting cascade. Thus, these agents prevent new clots from forming and limit or prevent extension of formed clots. The nurse is caring for a group of hospitalized clients. Which client is at greatest risk for infection and sepsis? An
18-year-old who had an emergency splenectomy An 18-year-old who had an emergency splenectomy Removal of the spleen causes reduced immune function. Without a spleen, the client is less able to remove disease-causing organisms, and is at increased risk for infection.
The nurse is assessing the nutritional status of a client with anemia. How does the nurse obtain information about the client's diet? Asks the client to rate his or her diet on a scale of 1 (poor) to 10 (excellent) Has the client write down everything he or she has eaten for the past week Having the client provide a list of items eaten in the past week is the most accurate way to find out what the client likes and dislikes, as well as what the client has been eating. It will provide information about "junk" food intake, as well as protein, vitamin, and mineral intake. The clinic nurse is discharging a 20-year-old client who had a bone marrow aspiration performed. What does the nurse advise the client to do? "Avoid contact sports or activity that may traumatize the site for 24 hours." "Place an ice pack over the site to reduce the bruising." Ice to the site will help limit bruising and tissue damage during the first 24 hours after the procedure. Contact sports and traumatic activity must be excluded for 48 hours, or 2 days. Which client does the medical unit charge nurse assign to an LPN/LVN? A 48-year-old with chronic microcytic anemia associated with alcohol use Chronic microcytic anemia is not considered life-threatening and can be assigned to an LPN/LVN. The nurse is starting the shift by making rounds. Which client does the nurse decide to assess first? A 42-year-old with anemia who is reporting
shortness of breath when ambulating down the hallway A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism The client with the nosebleed may be experiencing the bleeding as a result of excessive anticoagulation and should be assessed for the severity of the situation first. After reviewing the laboratory test results, the nurse calls the health care provider about which client? A 44-year-old receiving warfarin (Coumadin) with an international normalized ratio (INR) of 3.0 A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 The client with a fever is neutropenic and is at risk for sepsis unless interventions such as medications to improve the WBC level and antibiotics are prescribed. The INR of 3.0 in the 44-year-old indicates a therapeutic warfarin level. A platelet count of 150,000/mm3 in the 49-year-old is normal. An elevated reticulocyte count in the 52-year-old is expected after hemorrhage. A client has a bone marrow biopsy done. Which nursing intervention is the priority postprocedure? Applying pressure to the biopsy site Applying pressure to the biopsy site The initial action should be to stop bleeding by applying pressure to the site. Inspecting for ecchymoses, sending specimens to the laboratory, and teaching the client about activity levels will be done after hemostasis has been achieved. Sets with similar termsChapter 39: Assessment of the Hematologic System N…19 terms mrichert97 Chapter 39: Assessment of the Hematologic System19 terms jamesallenellisPLUS Hematologic System36 terms kimgrace808 Hematologic System nclex questions36 terms textucker5 Sets found in the same folderiggy adaptive quizzing63 terms rachelscott728 EAQ pt 2225 terms nursinggirl2001 Leukemia NCLEX Style Questions22 terms Sking0919 Med Surg - Chapter 39 - Assessment of the Hematolo…44 terms monyprak23 Other sets by this creatorCPR Final97 terms Maegan091119 Chapter 29 (History 152)64 terms Maegan091119 Chapter 28 (history)78 terms Maegan091119 Ch 2956 terms Maegan091119 Other Quizlet setsPPL Checkride59 terms peyo0415 Geography - Hazardous Earth - Questions…58 terms KwarleyPLUS Microbiology Exam 298 terms Jekonski15 Exam 1 Study Guide137 terms hallmara Related questionsQUESTION What are the clinical signs of Vitamin B12 deficiency? 15 answers QUESTION How long does it take to produce platelets? 9 answers QUESTION What causes platelets to stick to an injured vessel wall or to one another? 15 answers QUESTION what are the five kinds of WBC 13 answers What does a nurse do after a bone marrow aspiration?After aspiration, apply direct pressure over the puncture site according to hospital policy for 5 to 10 minutes until bleeding stops. Cover the site with a sterile dressing. Help the patient to a comfortable position. Monitor his vital signs and assess the puncture site for bleeding.
What procedure was used for the bone marrow aspiration?In a bone marrow aspiration, a health care provider uses a thin needle to remove a small amount of liquid bone marrow, usually from a spot in the back of your hipbone (pelvis). A bone marrow biopsy is often done at the same time. This second procedure removes a small piece of bone tissue and the enclosed marrow.
How is bone marrow aspiration performed and what are the nursing responsibilities during this procedure?The doctor prepares the biopsy site and injects a local anesthetic. He then inserts the needle through the skin, the subcutaneous tissue, and the cortex of the bone. The doctor removes the stylet from the needle and attaches a 10 to 20 ml syringe. He aspirates 0.2 to 0.5 ml of marrow and withdraws the needle.
What can I expect after a bone marrow biopsy?The biopsy site may feel sore for several days. You may have a bruise on the site. It can help to walk, take pain medicine, and put ice packs on the site. You will probably be able to return to work and your usual activities the day after the procedure.
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After a client has a bone marrow aspiration performed which action would the nurse take first
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