ati perfusion quizlet ATI Perfusion Quizlet - Nursing Elites
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Nursing Elites

ATI RN

ATI Perfusion Quizlet

1. During a physical assessment, the nurse examines the lymph nodes of a patient. Which assessment finding would be of most concern to the nurse?

Correct answer: A

Rationale: The correct answer is A. A 2-cm nontender supraclavicular node is of most concern because enlarged and nontender nodes in this area are highly suggestive of malignancies such as lymphoma. Choice B is less concerning as a 1-cm mobile and nontender axillary node is usually benign. Choice C, an inability to palpate any superficial lymph nodes, could be due to factors like obesity or edema, but it is not necessarily a cause for immediate concern. Choice D, firm inguinal nodes in a patient with an infected foot, may indicate a local reaction to infection rather than a systemic issue related to malignancy.

2. The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered?

Correct answer: C

Rationale: The correct answer is C, 'Hemoglobin level.' Pallor of the skin and nail beds is a sign of anemia, which is characterized by a low hemoglobin level. Anemia is a condition where there is a decreased number of red blood cells or hemoglobin in the blood, leading to reduced oxygen-carrying capacity. Checking the hemoglobin level would help confirm the presence and severity of anemia, guiding further diagnostic and treatment interventions. Choices A, B, and D are incorrect because platelet count, neutrophil count, and white blood cell count are not typically associated with the pallor of the skin and nail beds, which are more indicative of an underlying anemic condition.

3. The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care?

Correct answer: A

Rationale: The correct action to include in the plan of care for a thrombocytopenic patient is to avoid intramuscular injections. Thrombocytopenia is a condition characterized by a decreased number of platelets, which are essential for blood clotting. Intramuscular injections can pose a risk of bleeding in patients with low platelet counts. Encouraging increased oral fluids (choice B) is beneficial for hydration but does not directly address the risk of bleeding associated with thrombocytopenia. Checking temperature every 4 hours (choice C) is important for monitoring infection but does not specifically address the risk of bleeding. Increasing intake of iron-rich foods (choice D) is more related to addressing anemia, not the primary concern of bleeding in thrombocytopenia.

4. A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test?

Correct answer: A

Rationale: In the case of a patient with pancytopenia of unknown origin, a bone marrow biopsy is usually indicated to determine the cause. A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. Abdominal ultrasound (Choice B) is not typically used to diagnose pancytopenia. A Complete Blood Count (CBC) (Choice C) is a routine blood test and does not require a specific consent form. Activated Partial Thromboplastin Time (aPTT) (Choice D) is a coagulation test and not typically performed to diagnose pancytopenia.

5. A patient who has acute myelogenous leukemia develops an absolute neutrophil count of 850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate?

Correct answer: B

Rationale: The correct answer is B because filgrastim (Neupogen) is a medication used to stimulate the production of neutrophils. Teaching the patient to self-administer these injections can help increase the neutrophil count and reduce the risk of infection. Option A is incorrect as hospital admission may not be necessary if the patient can manage the condition at home. Option C is not ideal as discontinuing chemotherapy can impact the leukemia treatment. Option D is unrelated to managing neutropenia in this scenario.

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