Nokea
A client is scheduled for a bone marrow aspiration and is extremely apprehensive about having the procedure done. The nurse explains that there may be a feeling of pressure or discomfort when puncturing the bone. What intervention can the nurse provide to assist with this concern?
- A. Inform the client that he will not be able to move and will have to tolerate the discomfort for 20 minutes.
- B. Inform the client that if he is concerned that he will move when the bone is punctured, soft wrist restraints can be used if the client approves.
- C. Assist the client with focused imagery to avoid focusing on the procedure and any discomfort associated with it.
- D. Suggest chewing gum or eating candy in order to focus on something other than the discomfort.
Correct Answer: C
Rationale: Suggest distraction techniques to avoid focusing on the pressure or discomfort associated with puncturing the bone that may take approximately 20 minutes. Restraints should not be applied during the procedure because the client may not be able to determine if they are too tight. The client has a right to pain relief and should not have to 'tolerate' pain for 20 minutes. Chewing gum or eating candy may increase the client's risk for aspiration during the procedure.
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Undifferentiated cells that migrate to the thymus gland develop into which of the following?
- A. A lymphocytes
- B. D lymphocytes
- C. T lymphocytes
- D. S lymphocytes
Correct Answer: C
Rationale: The thymus gland is lymphatic tissue in the upper chest that contains undifferentiated stem cells released from bone marrow. Once the undifferentiated cells migrate to the thymus gland, they develop into T lymphocytes because they are thymus derived. The other options are distractors for this question.
A client is brought to the emergency department with suspected bleeding esophageal varices. Which hemoglobin level should the nurse immediately report to the physician?
- A. 13.0 g/dL
- B. 10.2 g/dL
- C. 5.0 g/dL
- D. 11.4 g/dL
Correct Answer: C
Rationale: The nurse should immediately report a 5.0 g/dL, which is a critical low level. A 13.0 g/dL is a normal level, 11.4 is slightly low, and 10.2 is low.
A student nurse is having difficulty understanding the function of globulins. What information can the client provide to the student regarding the function of globulins?
- A. Immunologic agents
- B. Destruction of invading organisms
- C. Precursors to clot formation
- D. Transport of oxygen to the tissues
Correct Answer: A
Rationale: Globulins function primarily as immunologic agents; they prevent or modify some types of infectious diseases. Globulins do not destroy invading organisms, participate in clot formation, or transport oxygen to the tissues.
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 nurse is providing care to a cancer client. Which protein in plasma functions primarily as immunologic agents?
- A. Gamma globulins
- B. Albumin
- C. Fibrinogen
- D. Beta globulins
Correct Answer: A
Rationale: Globulins are divided into three groups: alpha, beta, and gamma. The gamma globulins are also called immunoglobulins. Globulins function primarily as immunologic agents; they prevent or modify some types of infectious diseases. The other options are incorrect.