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 crucial nursing action is monitoring for bleeding, as this procedure can cause significant bleeding due to the penetration of bone. It is essential to assess for any signs of bleeding such as increased pain, swelling, bruising, or hematoma formation. Prompt identification and management of bleeding are vital to prevent complications such as hematoma formation or hemorrhage. Encouraging oral fluids (B) and administering analgesics (C) are important but not as critical as monitoring for bleeding. Monitoring the puncture site for infection (D) is also important but is a secondary concern compared to assessing for bleeding immediately post-procedure.
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 the dye used in lymphangiography can cause bluish skin and urine for up to 2 days. This is a known side effect of the procedure and is not a cause for concern. Choice A is incorrect because dismissing the patient's concern without explanation is not appropriate. Choice B is incorrect because there is no need to notify the RN and physician immediately for this known side effect. Choice C is incorrect because the blue urine does not necessarily indicate abnormal results, but rather a normal reaction to the dye used.
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 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 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 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 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, 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