Nokea
The nurse is caring for a newly admitted patient whose complete blood count (CBC) shows a 'shift to the left.' Which of the following assessments should the nurse monitor in the plan of care?
- A. Cool extremities
- B. Pallor and weakness
- C. Elevated temperature
- D. Low oxygen saturation
Correct Answer: C
Rationale: The term shift to the left indicates that the number of immature polymorphonuclear neutrophils, or bands, is elevated and is a sign of severe infection. There is no indication that the patient is at risk for hypoxemia, pallor or weakness, or cool extremities.
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The nurse is obtaining a health history from a patient and notes numerous petechiae. Which of the following assessments should the nurse anticipate?
- A. Bruising on the skin
- B. Pinpoint purplish-red lesions
- C. Small focal red lesions
- D. Brown spots on mucous membranes
Correct Answer: B
Rationale: Petechiae are small, purplish-red lesions. Ecchymosis is bruising on the skin. Small focal red lesions are telangiectasia. Purpura are small hemorrhages on the skin or mucous membranes resulting in a rash of purple, red, or brown spots.
The health care provider performs a bone marrow aspiration from the left posterior iliac crest on a patient with pancytopenia. Which of the following actions should the nurse implement following the procedure?
- A. Elevate the head of the bed to 45 degrees
- B. Apply a sterile Band-Aid at the aspiration site
- C. Use half-inch sterile gauze to pack the wound
- D. Apply a pressure dressing on the aspiration site
Correct Answer: D
Rationale: A pressure dressing is used to cover the aspiration site. The wound after bone marrow biopsy is small and will not be packed with gauze. There is no indication that the head needs to be elevated for this patient.
While examining the lymph nodes during physical assessment, the nurse would be most concerned about which of the following findings?
- A. A 2-cm nontender supraclavicular node
- B. A 1-cm mobile and nontender axillary node
- C. An inability to palpate any superficial lymph nodes
- D. Firm inguinal nodes in a patient with an infected foot
Correct Answer: A
Rationale: Enlarged and nontender nodes are most suggestive of malignancy such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5-1 cm and nontender.
The nurse is reviewing laboratory data for an older-adult patient. Which of the following results should be of most concern?
- A. White blood cell (WBC) count of 3.5 x 10^9/L
- B. Hematocrit of 37%
- C. Platelet count of 400 x 10^9/L
- D. Hemoglobin of 118 g/L
Correct Answer: A
Rationale: The total WBC count is not usually affected by aging, and the low WBC here would indicate that the patient's immune function may be compromised. The platelet count is normal. The slight decrease in hemoglobin and hematocrit is not unusual for an older patient.
The nurse is evaluating the red cell indices result of a patient's laboratory report. Which of the following interpretations is correct related to a low mean corpuscular volume (MCV)?
- A. Hypochromic red blood cells (RBCs)
- B. Inadequate numbers of RBCs
- C. Low hemoglobin in the RBCs
- D. Small size of the RBCs
Correct Answer: D
Rationale: The MCV is low when the RBCs are smaller than normal. Inadequate numbers of RBCs are an indication of anemia. Low levels of hemoglobin in the RBCs and hypochromic RBCs result in a low mean corpuscular hemoglobin (MCH).