Nokea
The nurse is providing discharge teaching to a patient who has had an emergency splenectomy following an automobile accident. Which of the following events should the nurse inform the patient that they are at an increased risk of developing?
- A. Infection
- B. Lymphedema
- C. Persistent anemia
- D. Prolonged bleeding
Correct Answer: A
Rationale: The spleen plays a major role in immune function. Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after splenectomy.
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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 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 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 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.
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.