Nokea
When obtaining vital signs from a client who has reduced erythrocyte production and a hemoglobin level of 8.2 g/dL, what results would be indicative of these lab studies?
- A. Heart rate of 120 beats/minute
- B. Respiratory rate of 16 breaths/minute
- C. Blood pressure of 140/90 mm Hg
- D. Oxygen saturation of 95%
Correct Answer: A
Rationale: A rapid pulse rate can indicate reduced erythrocytes or inadequate hemoglobin levels. The respiratory rate for this client is within normal range. Hypertension is not indicative of a low hemoglobin level, and what is usually seen would be hypotension. The oxygen saturation level is within normal range.
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The nurse is preparing the client for a bone marrow aspiration at the posterior iliac crest. What would be the best position for the nurse to place the client in for the test?
- A. Head of the bed in a 90?° semi-Fowler's position
- B. Prone position
- C. On the side or back
- D. Lithotomy position
Correct Answer: C
Rationale: The client should be positioned on the back or side to facilitate access to the aspiration site. The 90?° semi-Fowler's and prone position would not allow adequate access to the bone marrow aspiration site. The lithotomy position is used for genitourinary and gynecological testing and procedures.
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 caring for three clients who have the following blood count values: Client A has 24,500/mm?³ white blood cells (WBCs), client B has 13.4 g/dL hemoglobin, and client C has a 250,000/mm?³ platelet count. Which statement correctly describes the condition of each client?
- A. Client A has a normal WBC count, client B has a higher hemoglobin count than normal, and client C has a normal platelet count.
- B. Client A has a higher WBC count than normal, client B has a normal hemoglobin count, and client C has a normal platelet count.
- C. Client A has a higher WBC count than normal, client B has a normal hemoglobin count, and client C has a higher platelet count than normal.
- D. Client A has a lower WBC count than normal, client B has a normal hemoglobin count, and client C has a normal platelet count.
Correct Answer: B
Rationale: The normal leukocyte count is between 5000 and 10,000/mm?³. Client A has an increased number of leukocytes greater than 10,000/mm?³ and hence has leukocytosis. In adults, the normal amount of hemoglobin is 12.0 to 17.4 g/dL; therefore, client B has a normal hemoglobin count. A normal circulating platelet count is 150,000 to 350,000/mm?³ platelets; therefore, client C has a normal platelet count.
The nurse is inspecting the tonsils of a client that complains of a sore throat for size and appearance. What is the appropriate documentation for an observation of tonsils that touch the uvula?
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: C
Rationale: A scale of 3 is when the tonsils touch the uvula. A 1 is when the tonsils are visible, a 2 is when the tonsils extend medially toward the uvula, and a 4 is when the tonsils touch each other.
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.