ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 30 : Introduction to the Hematopoietic and Lymphatic Systems Questions
Question 1 of 5
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?
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.
Question 2 of 5
The nurse is inspecting the tonsils for a client with a fever and sore throat. The nurse observes purulent exudate on the surface of the tonsils. What does this finding indicate to the nurse?
Correct Answer: D
Rationale: Purulent exudate on the surface of the tonsils suggests tonsillitis. Filariasis is also known as elephantiasis and is a consequence of a roundworm infection in which the lymphatic vessels become occluded. An abscess would not have purulent drainage on the surface unless ruptured.
Question 3 of 5
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?
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.
Question 4 of 5
A client is scheduled for a bone marrow aspiration and is extremely apprehensive about having the procedure done. The nurse explains that there may be a feeling of pressure or discomfort when puncturing the bone. What intervention can the nurse provide to assist with this concern?
Correct Answer: C
Rationale: Suggest distraction techniques to avoid focusing on the pressure or discomfort associated with puncturing the bone that may take approximately 20 minutes. Restraints should not be applied during the procedure because the client may not be able to determine if they are too tight. The client has a right to pain relief and should not have to 'tolerate' pain for 20 minutes. Chewing gum or eating candy may increase the client's risk for aspiration during the procedure.
Question 5 of 5
The nurse will be assisting the physician with a bone marrow aspiration. Where should the nurse cleanse, clip hair, and drape the skin prior to the procedure?
Correct Answer: A
Rationale: The posterior superior iliac crest is the preferred site because no vital organs or blood vessels are nearby. The anterior tibia, radius, or metatarsal area are not used for bone marrow aspirations.