ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 30 Questions
Question 1 of 5
The nurse is observing the skin of a client who is taking medications that depress the hematopoietic system and notices multiple areas of ecchymosis on the arms; bleeding for a prolonged period after an IV was started; and reports of black, tarry stool. What does the nurse understand may be a side effect of this medication that the client displays?
Correct Answer: C
Rationale: Signs of thrombocytopenia include unusual or easy bleeding; oozing from injection sites; bleeding gums; and dark, tarry stools. Leukocytosis would cause fever as well as other signs and symptoms of infection. Leukopenia symptoms are fever, sore throat, and chills. Neutropenia reduces the client's ability to fight infection and makes susceptible to microorganisms.
Question 2 of 5
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?
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.
Question 3 of 5
Undifferentiated cells that migrate to the thymus gland develop into which of the following?
Correct Answer: C
Rationale: The thymus gland is lymphatic tissue in the upper chest that contains undifferentiated stem cells released from bone marrow. Once the undifferentiated cells migrate to the thymus gland, they develop into T lymphocytes because they are thymus derived. The other options are distractors for this question.
Question 4 of 5
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?
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.
Question 5 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.