Nokea
A client has been involved in an automobile accident and is assessed to have an enlarged spleen. What does the nurse understand is the significance of attempting to prevent unnecessary removal of the spleen for this client?
- A. The spleen is a large lymph node and takes waste debris away.
- B. The spleen is a lymphatic structure and assists with phagocytosis
- C. The spleen is lymphoid tissue in the upper chest that contains stem cells.
- D. The spleen assists with blood clotting.
Correct Answer: B
Rationale: The spleen is the largest lymphatic structure, is a reservoir of blood, and contains phagocytes that engulf damaged erythrocytes and foreign substances. Lymph fluid takes waste debris away. The thymus is lymphoid tissue that is in the upper chest and contains stem cells. The spleen does not assist with blood clotting.
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Macrophages attack and destroy foreign substances to the body. Where does this action occur?
- A. At the site of trauma
- B. In the lymph node
- C. In the vascular system
- D. In the thymus
Correct Answer: B
Rationale: As lymph passes through the node, macrophages attack and engulf foreign substances such as bacteria and viruses, abnormal body cells, and other debris. The other options are incorrect.
The nurse is assisting the physician with obtaining a sample to determine the status of blood cell formation. What type of procedure will the nurse have prepared the client for?
- A. A bone marrow aspiration
- B. A Schilling test
- C. A thoracentesis
- D. A urine sample
Correct Answer: A
Rationale: A bone marrow aspiration is performed to determine the status of blood cell formation. In this procedure, the physician applies local anesthesia and removes bone marrow from the posterior iliac crest or the sternum. The marrow is examined for the types and percentage of immature and maturing blood cells.
Albumin is a protein in the plasma portion of the blood. Under normal conditions, albumin cannot pass through the wall of a capillary. What significance is this for the vascular compartment?
- A. Helps push oxygen into the tissues of the body
- B. Retains leukocytes in the vascular compartment
- C. Helps retain fluid in the vascular compartment
- D. Absorbs carbon dioxide from the tissues for transport to the lungs
Correct Answer: C
Rationale: Under normal conditions, albumin cannot pass through a capillary wall. Consequently, albumin helps maintain the osmotic pressure that retains fluid in the vascular compartment. Albumin does not push oxygen into the tissues of the body or absorb carbon dioxide for transport to the lungs. Albumin also does not retain leukocytes in the vascular compartment.
A client informs the nurse that he is having a difficult time coping with seasonal allergies and has taken some over-the-counter medications to assist with control of symptoms. What results would indicate to the nurse that the client does have allergies?
- A. Elevated eosinophils
- B. Elevated basophils
- C. Elevated monocytes
- D. Elevated neutrophils
Correct Answer: A
Rationale: Eosinophils phagocytize foreign material. Their numbers increase in allergies, some dermatologic disorders, and parasitic infections. Basophils are also capable of phagocytosis; they are active in allergic contact dermatitis and some delayed hypersensitivity reactions. Monocytes engulf microbial invaders and display the antigenic surface to T lymphocytes. Neutrophils are a major component of the inflammatory response and defense against bacterial infection.
The nurse is preparing the client for a bone marrow aspiration at the posterior iliac crest. What would be the best position for the nurse to place the client in for the test?
- A. Head of the bed in a 90?° semi-Fowler's position
- B. Prone position
- C. On the side or back
- D. Lithotomy position
Correct Answer: C
Rationale: The client should be positioned on the back or side to facilitate access to the aspiration site. The 90?° semi-Fowler's and prone position would not allow adequate access to the bone marrow aspiration site. The lithotomy position is used for genitourinary and gynecological testing and procedures.