ATI RN
Hematological System Questions
Question 1 of 5
The nurse is caring for a patient having a bone marrow biopsy. What nursing action is the most important following the biopsy?
Correct Answer: A
Rationale: The correct answer is A: Observe for bleeding. After a bone marrow biopsy, the most important nursing action is to monitor for bleeding, as the patient is at risk for hemorrhage due to the invasive nature of the procedure. Observing for bleeding includes assessing the dressing, vital signs, and the puncture site for any signs of hematoma or excessive bleeding. Encouraging oral fluids (B) helps prevent dehydration but is not the most critical post-biopsy action. Administering an analgesic (C) for pain is important for patient comfort but does not address the immediate risk of bleeding. Monitoring for infection (D) is important but is not the priority immediately following the biopsy.
Question 2 of 5
A patient who underwent lymphangiography the day before asks the licensed practical nurse (LPN), “Why does my urine look blue?†What should the LPN respond to this patient's concern?
Correct Answer: D
Rationale: The correct answer is D because lymphangiography involves injecting a dye into the lymphatic system, which can cause the urine to appear blue temporarily. The LPN should reassure the patient that this is a normal and expected side effect of the procedure. Choice A is incorrect as it lacks explanation and may not address the patient's concern. Choice B is unnecessary as there is no urgent need to notify the RN and physician. Choice C is incorrect because blue urine does not necessarily indicate abnormal results, but rather a common side effect of the dye used in the procedure.
Question 3 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 minimize the risk of bleeding from puncture sites. Placing the patient in protective isolation (B) is unnecessary for low platelet count. Wearing a mask (C) is not directly related to platelet count. Documenting rectal temperatures (D) is not a priority when managing thrombocytopenia.
Question 4 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 lack of intrinsic factor, leading to vitamin B12 deficiency. This deficiency can result in neurological symptoms such as numbness and tingling in the extremities. Yellow-tinged sclerae (A) are more indicative of jaundice. A shiny smooth tongue (B) is a characteristic finding in glossitis, not specific to pernicious anemia. Gum bleeding and tenderness (D) are more commonly associated with periodontal disease rather than pernicious anemia.
Question 5 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 that works by inhibiting thrombin formation, thus preventing blood clots. Thrombin is a key enzyme in the coagulation cascade. Choices B and D are incorrect because rivaroxaban specifically targets factor Xa and not fibrinogen or vitamin K. Choice C is incorrect as rivaroxaban does not actually "thin" the blood; it works by preventing clot formation.