Nokea
The nurse observes that a client who had an arterial blood gas performed 30 minutes ago is still oozing blood from the puncture site. Pressure was held to the site for 5 minutes after the puncture and another 5 minutes when the site was still oozing. What factor does the nurse know will participate in the ability for the blood to clot?
- A. Platelets
- B. Leukocytes
- C. Erythrocytes
- D. Albumin
Correct Answer: A
Rationale: Platelets participate in clotting blood. Leukocytes protect against infection. Erythrocytes transport oxygen, and albumin affects intravascular osmotic pressure.
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A client is being treated for anemia and has a hemoglobin level of 9.6 g/dL. What does the nurse understand is the basic nutritional component of heme in hemoglobin that the client may be deficient in?
- A. Folic acid
- B. Copper
- C. Protein
- D. Iron
Correct Answer: D
Rationale: Iron is the basic nutritional component of heme in hemoglobin. Folic acid is essential for the maturation of red blood cells. Copper (minute amount) is involved in the transfer of iron from storage to plasma.
A client is admitted to the emergency department with significant blood loss. The physician prescribes 2 units of packed red blood cells to be transfused immediately. Which blood groups would be compatible with his O Rh-positive blood group?
- A. O Rh-positive or O Rh-negative
- B. Only O Rh-positive
- C. Only O Rh-negative
- D. AB Rh-positive or Rh-negative
Correct Answer: A
Rationale: People with Rh-positive blood can receive Rh-positive or Rh-negative blood because a negative Rh indicates a missing Rh factor. Antibodies, immunoglobulins in plasma that inactivate any substance that is non-self, react with incompatible red blood cell antigens. Therefore, people with type O blood are universal donors because they do not have antigens on the red cell membrane. Therefore, the client can be transfused with either O Rh-positive or O Rh-negative blood.
The nurse is assisting the physician with obtaining a sample to determine the status of blood cell formation. What type of procedure will the nurse have prepared the client for?
- A. A bone marrow aspiration
- B. A Schilling test
- C. A thoracentesis
- D. A urine sample
Correct Answer: A
Rationale: A bone marrow aspiration is performed to determine the status of blood cell formation. In this procedure, the physician applies local anesthesia and removes bone marrow from the posterior iliac crest or the sternum. The marrow is examined for the types and percentage of immature and maturing blood cells.
A client has been involved in an automobile accident and is assessed to have an enlarged spleen. What does the nurse understand is the significance of attempting to prevent unnecessary removal of the spleen for this client?
- A. The spleen is a large lymph node and takes waste debris away.
- B. The spleen is a lymphatic structure and assists with phagocytosis
- C. The spleen is lymphoid tissue in the upper chest that contains stem cells.
- D. The spleen assists with blood clotting.
Correct Answer: B
Rationale: The spleen is the largest lymphatic structure, is a reservoir of blood, and contains phagocytes that engulf damaged erythrocytes and foreign substances. Lymph fluid takes waste debris away. The thymus is lymphoid tissue that is in the upper chest and contains stem cells. The spleen does not assist with blood clotting.
A client's family member asks what hematopoiesis is. What should the nurse tell the family member?
- A. The manufacture and development of blood cells
- B. The production of lymphatic fluid in the body
- C. The making of red blood cells and lymph
- D. The development of lymph in the bone marrow
Correct Answer: A
Rationale: Hematopoiesis is the manufacture and development of blood cells. It also considers the lymphatic system, which includes the thymus gland and spleen; this system assists in the maturation of certain lymphocytes. Hematopoiesis is not the production of lymphatic fluid or the development of lymph in the bone marrow.