Nokea
The nurse is caring for a patient with persistent iron-deficiency anemia. Which of the following assessment findings should the nurse anticipate?
- A. Yellow-tinged sclerae
- B. Shiny, smooth tongue
- C. Numbness of the extremities
- D. Gum bleeding and tenderness
Correct Answer: B
Rationale: Loss of the papillae of the tongue occurs with persistent iron-deficiency. Scleral jaundice is associated with hemolysis, gum bleeding and tenderness occur with thrombocytopenia or neutropenia, and extremity numbness is associated with vitamin B12 deficiency or pernicious anemia.
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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 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.
The nurse is caring for a patient with pancytopenia of unknown origin who is confused and is scheduled for the following diagnostic tests. Which of the following tests should the nurse contact the patient's family member to obtain a signed consent form?
- A. ABO blood typing
- B. Bone marrow biopsy
- C. Abdominal ultrasound
- D. Complete blood count (CBC)
Correct Answer: B
Rationale: Bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent by the patient or family.
A patient's complete blood count shows a hemoglobin of 200 g/L and a hematocrit of 54%. Which of the following questions should the nurse ask to determine possible causes of this finding?
- A. Has there been any recent weight loss?
- B. Do you have any problems with your vision?
- C. What is your intake of fruits and vegetables?
- D. Have you noticed any dark or bloody stools?
Correct Answer: B
Rationale: The hemoglobin and hematocrit results indicate polycythemia, which may cause visual abnormalities. The other questions will be appropriate for patients who are anemic.
The nurse is caring for a patient whose complete blood count (CBC) and differential indicate that the patient is neutropenic. Which of the following actions should the nurse include in the plan of care?
- A. Avoid intramuscular injections
- B. Encourage increased oral fluids
- C. Check temperature every 4 hours
- D. Increase intake of iron-rich foods
Correct Answer: C
Rationale: Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. The other actions would not address the patient's neutropenia.