ATI RN
Hematological System Questions
Question 1 of 5
A patient is prescribed to receive 2 units of packed red blood cells. What approach should the nurse use to ensure that the correct blood will be provided to this patient?
Correct Answer: C
Rationale: The correct answer is C: Follow the organization's verification process. This approach ensures patient safety by using a systematic verification process to match the blood product with the patient, including checking the patient's identification, verifying the order, and confirming the blood product before administration. Checking the patient's arm band (A) may not be sufficient for blood product verification. Checking the order on the medical record (B) is important but may not involve the necessary steps to ensure correct blood matching. Assuming the correct blood was provided (D) is dangerous and can lead to serious consequences if an error occurs.
Question 2 of 5
A patient has a platelet count of 75,000 /mm³. What action should the nurse take to support this patient?
Correct Answer: A
Rationale: The correct action is to restrict blood draws. With a platelet count of 75,000 /mm³, the patient is at risk for bleeding due to thrombocytopenia. Restricting blood draws helps prevent unnecessary bleeding. Placing in protective isolation (B) is not necessary for low platelet count. Wearing a mask (C) does not directly address the risk of bleeding. Documenting rectal temperatures (D) is unrelated to managing thrombocytopenia.
Question 3 of 5
The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: Numbness of the extremities. Pernicious anemia is caused by a deficiency in vitamin B12, leading to nerve damage. Numbness in the extremities is a common symptom due to neurological complications. Yellow-tinged sclerae (A) are seen in jaundice, not pernicious anemia. A shiny smooth tongue (B) is characteristic of glossitis, not pernicious anemia. Gum bleeding and tenderness (D) are more indicative of periodontal disease or vitamin C deficiency, not pernicious anemia.
Question 4 of 5
A client is receiving rivaroxaban (Xarelto) and asks the nurse to explain how it works. What response by the nurse is best?
Correct Answer: A
Rationale: The correct answer is A: It inhibits thrombin. Rivaroxaban is a direct factor Xa inhibitor, which works by specifically inhibiting the activity of factor Xa, a key enzyme in the coagulation cascade. By inhibiting factor Xa, rivaroxaban prevents the formation of thrombin, a crucial enzyme in the blood clotting process. Thrombin is responsible for converting fibrinogen to fibrin, which forms the meshwork of a blood clot. Therefore, by inhibiting thrombin formation, rivaroxaban effectively prevents blood clots from forming. Choice B is incorrect because rivaroxaban does not directly inhibit fibrinogen; it acts upstream by inhibiting factor Xa. Choice C is incorrect because rivaroxaban does not actually "thin" the blood like warfarin or heparin; it specifically targets factor Xa. Choice D is incorrect because rivaroxaban does not work against vitamin K like warfarin
Question 5 of 5
A client is having a bone marrow biopsy and is extremely anxious. What action by the nurse is best?
Correct Answer: A
Rationale: The correct answer is A. Assessing client fears and coping mechanisms is the best action because it allows the nurse to understand the client's specific concerns and provide individualized support. This helps address the root cause of anxiety and establish trust. Reassuring the client (B) may not address the underlying fears. Sedating the client (C) without addressing the anxiety may lead to dependency on sedatives. Telling the client they will be asleep (D) may create false expectations and not address the client's emotional needs. Assessing fears and coping mechanisms enables tailored support, promoting trust and comfort.