Nokea
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.
You may also like to solve these questions
The nurse is reviewing the complete blood count (CBC) for a patient admitted with abdominal pain. Which of the following information will be most important for the nurse to communicate to the health care provider?
- A. Monocytes 4%
- B. Hemoglobin 116 g/L
- C. Platelet count 44 x 10^9/L
- D. White blood cells 13.5 x 10^9/L
Correct Answer: D
Rationale: The elevation in WBCs indicates that an abdominal infection may be the cause of the patient's pain and that further diagnostic testing is needed. The monocytes are at a normal level. The slight decreases in hemoglobin and platelet count also would be reported but would not require any immediate action.
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.
The nurse is caring for a patient who had an intraoperative hemorrhage 12 hours ago. Which of the following laboratory results should the nurse anticipate?
- A. Hematocrit of 45%
- B. Hemoglobin of 132 g/L
- C. Decreased white blood cell (WBC) count
- D. Elevated reticulocyte count
Correct Answer: D
Rationale: Hemorrhage causes the release of more immature RBCs from the bone marrow into the circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.
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.
The nurse is caring for a patient who is receiving heparin. Which of the following laboratory tests should the nurse monitor?
- A. Prothrombin time (PT)
- B. Fibrin degradation products (FDP)
- C. International normalized ratio (INR)
- D. Activated partial thromboplastin time (aPTT)
Correct Answer: D
Rationale: aPTT testing is used to determine whether heparin is at a therapeutic level. FDP is useful in diagnosis of problems such as disseminated intravascular coagulation (DIC). PT and INR are most commonly used to test for therapeutic levels of warfarin.