Ch. 36- Assessment of the Hematologic System

Stem cells can develop into:

• red blood cells

• white blood cells

• platelets

• bone marrow

What occurs in Primary Hemostasis?

• vasoconstriction

• platelet aggregation

• formation of a platelet plug

• activation of the 13 clotting factors

The nurse is assessing an older client for any potential hematologic health problem. Which assessment finding is the most

significant and would be reported to the primary health care provider?

• Poor skin turgor on both forearms

• Multiple petechiae and large bruises

• Dry, flaky skin on arms and legs

• Decreased body hair distribution

Answer explanation

The presence of multiple petechiae and large bruises indicate a possible problem with blood clotting. Older adults typically have

poor skin turgor and dry, flaky skin due to decreased body fluid as a result of aging. They also lose body hair or have thinning hair

as a normal change of aging.

A nurse is assessing a dark-skinned client for pallor. What nursing assessment is best to assess for pallor in this client?

• Assess the conjunctiva of the eye.

• Have the patient open the hand widely.

• Look at the roof of the patient’s mouth.

• Palpate for areas of mild swelling.

Answer explanation

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.

A hospitalized client has a platelet count of 58,000/mm3 (58 × 109/L). What action by the nurse is most appropriate?

• Encourage high-protein foods.

• Institute neutropenic precautions.

• Limit visitors to healthy adults.

• Place the client on safety precautions.

Answer explanation

With a platelet count between 40,000 and 80,000/mm3 (40 and 80 × 109/L), clients are at risk of prolonged bleeding even after

minor trauma. The nurse would place the client on safety or bleeding precautions as the most appropriate action. High-protein

foods, while healthy, are not the priority. Neutropenic precautions are not needed as the patient’s white blood cell count is not low.

Limiting visitors would also be more likely related to a low white blood cell count.

A client is having a bone marrow aspiration and biopsy. What action by the nurse takes priority?

• Administer pain medication first.

• Ensure that valid consent is in the medical record.

• Have the client shower in the morning.

• Premedicate the client with sedatives.

Answer explanation

A bone marrow aspiration and 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.

What is the nurse’s priority when caring for a client who just completed a bone marrow aspiration and biopsy?

• Teach the client to avoid activity for 24 to 48 hours to prevent infection.

• Administer a nonsteroidal anti-inflammatory drug (NSAID) to promote comfort.

• Check the pressure dressing frequently for signs of excessive or active bleeding.

• Report the laboratory results to the primary health care provider.

Answer explanation

The client having a bone marrow aspiration and biopsy has a puncture wound from the large needle used to extract the bone

marrow. Therefore, the client is at risk for bleeding. A NSAID should not be given because it can cause bleeding. Avoiding activity

helps to prevent bleeding, not infection, and reporting the results of the biopsy is not the responsibility of the nurse.

A nurse is caring for four clients. After reviewing today’s laboratory results, which client would the nurse assess first?

• Client with an international normalized ratio of 2.8

• Client with a platelet count of 128,000/mm3 (128 × 109/L).

• Client with a prothrombin time (PT) of 28 seconds

• Client with a red blood cell count of 5.1 million/mcL (5.1 × 1012/L)

Answer explanation

A normal PT is 11 to 12.5 seconds. This client is at high risk of bleeding with a PT of 28 seconds. The other values are within

normal limits.

A client is having a bone marrow aspiration and biopsy and is extremely anxious. What action by the nurse is the most

appropriate?

• Assess the client’s fears and coping mechanisms.

• Reassure the client that this is a common test.

• Sedate the client prior to the procedure.

• Tell the client that he or she will be asleep.

Answer explanation

Assessing the client’s specific fears and coping mechanisms helps guide the nurse in providing holistic care that best meets 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.

A client is having a radioisotopic imaging scan. What action by the nurse is most important?

• Assess the client for shellfish allergies.

• Place the client on radiation precautions.

• Sedate the client before the scan.

• Teach the client about the procedure.

Answer explanation

The nurse should ensure that teaching is done and the client understands the procedure. Contrast dye is not used, so shellfish/iodine

allergies are not related. The client will not be radioactive and does not need radiation precautions. Sedation is not used in this

procedure.