Chapter 41: Assessment of the Hematologic System

Chapter 41: Assessment of the Hematologic System

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

1. The nurse helps to ambulate a client who has anemia. Which clinical manifestation indicates that the client is not tolerating the activity?

a.	Blood pressure of 120/90 mm Hg
b.	Heart rate of 110 beats/min
c.	Pulse oximetry reading of 95%
d.	Respiratory rate of 20 breaths/min

 

 

ANS:  B

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.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Physiological Adaptation—Pathophysiology)

MSC:  Integrated Process: Nursing Process (Analysis)

 

2. The nurse is assessing a client with liver failure. Which assessment is the highest priority for this client?

a.	Auscultation for bowel sounds
b.	Assessing for deep vein thrombosis
c.	Monitoring of blood pressure hourly
d.	Assessing for signs of bleeding

 

 

ANS:  D

All these options are important in assessment of the client, but the most important action is assessment for signs of bleeding. The liver is the site of production of prothrombin and most of the blood-clotting factors. Clients with liver failure run a high risk of having problems with bleeding.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Physiological Integrity (Reduction of Risk Potential—Potential for Complications from Surgical Procedures and Health Alterations)

MSC:  Integrated Process: Nursing Process (Assessment)

 

3. The nurse observes yellow-tinged sclera in a client with dark skin. Based on this assessment finding, what does the nurse do next?

a.	Assess the client’s pulses.
b.	Examine the soles of the client’s feet.
c.	Inspect the client’s hard palate.
d.	Auscultate the client’s lung sounds.

 

 

ANS:  C

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.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC:  Integrated Process: Nursing Process (Assessment)

 

4. The nurse is assessing a client with numerous areas of bruising. Which question does the nurse ask to determine the cause of this finding?

a.	“Do you take aspirin?”
b.	“How often do you exercise?”
c.	“Are you a vegetarian?”
d.	“How often do you take Tylenol?”

 

 

ANS:  A

Platelet aggregation is essential for blood clotting. An inability to clot blood when an injury occurs can result in bleeding, which would cause bruising. Aspirin is a drug that interferes with platelet aggregation and has the ability to “plug” an extrinsic event, such as trauma. Vitamin K found in green vegetables enhances clotting factors, which would improve the ability to stop bleeding associated with an extrinsic event. Acetaminophen (Tylenol) and exercise do not inhibit clotting factors.

 

DIF:    Cognitive Level: Application/Applying or higher               REF:   N/A

TOP:   Client Needs Category: Health Promotion and Maintenance (Health Screening)

MSC:  Integrated Process: Nursing Process (Assessment)