Nokea
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.
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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 evaluating the red cell indices result of a patient's laboratory report. Which of the following interpretations is correct related to a low mean corpuscular volume (MCV)?
- A. Hypochromic red blood cells (RBCs)
- B. Inadequate numbers of RBCs
- C. Low hemoglobin in the RBCs
- D. Small size of the RBCs
Correct Answer: D
Rationale: The MCV is low when the RBCs are smaller than normal. Inadequate numbers of RBCs are an indication of anemia. Low levels of hemoglobin in the RBCs and hypochromic RBCs result in a low mean corpuscular hemoglobin (MCH).
The nurse is reviewing the laboratory results of clotting study tests for the patient. Which of the following findings should the nurse identify as abnormal?
- A. Activated clotting time 118 seconds
- B. Activated partial thromboplastin time 40 seconds
- C. D-dimer 200 mg/L
- D. Fibrinogen 5 g/L
- E. Prothrombin time 21 seconds
Correct Answer: B,D,E
Rationale: The activated partial thromboplastin time is elevated (normal: 25-35 seconds), fibrinogen is elevated (normal: 2-4 g/L), and the prothrombin time is elevated (normal: 11-16 seconds). The activated clotting time is within normal limits (70-120 seconds). The D-dimer is within normal limits (< 250 ng/mL).
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.
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.