Chapter 39: Assessment of the Hematologic System - Nurselytic

Correct Answer: A

Rationale:
To assess pallor in dark-skinned people, assess the conjunctiva of the eye or the mucous membranes. Looking at the roof of the mouth can reveal jaundice. Opening the hand widely is not related to pallor, nor is palpating for mild swelling.

Correct Answer: D

Rationale: With a platelet count between 40,000 and 80,000 / mm3, clients are at risk of prolonged bleeding even after minor trauma. The nurse should place the client on safety precautions. High-protein foods, while healthy, are not the priority. Neutropenia precautions are not needed as the client's white blood cell count is not low.

Correct Answer: B

Rationale: A bone marrow biopsy is an invasive procedure that requires informed consent. Pain medication and sedation are important components of care for this client but do not take priority. The client may or may not need or be able to shower.

Correct Answer: C

Rationale: A normal PT is 11 to 12.5 seconds. This client is at high risk of bleeding. The other values are within normal limits.

Correct Answer: A

Rationale: Assessing the client's specific fears and coping mechanisms helps guide the nurse in providing holistic care that best issues the client's needs. Reassurance will be helpful but is not the best option. Sedation is usually used. The client may or may not be totally asleep during the procedure.