Your patient has suspected aplastic anemia and has just returned to the unit to be cared for by you after having bone marrow biopsy done to confirm the diagnosis. Which of the following is the MOST appropriate nursing action?
Assess the patient's lower back for bleeding
Apply a heat pack to the biopsy site for comfort
Have the patient remain bedbound and NPO for 4-6 hours
Give aspirin for hip pain
The Correct Answer is A
A. This is a crucial action following a bone marrow biopsy, as there is a risk of bleeding at the biopsy site. Monitoring for signs of bleeding or hematoma formation is essential to prevent complications, making this a highly appropriate nursing action.
B. While applying heat may provide comfort, it is generally not recommended immediately after a biopsy because it can increase blood flow to the area and potentially exacerbate bleeding. Thus, this action may not be appropriate right after the procedure.
C. While some level of rest is important after a procedure, keeping the patient NPO (nothing by mouth) is unnecessary unless there are specific orders due to anesthesia or other considerations. Additionally, remaining bedbound could increase discomfort or risk of complications like deep vein thrombosis (DVT) if not warranted.
D. Aspirin should be avoided in this scenario because it is an anticoagulant and can increase the risk of bleeding, particularly after a procedure like a bone marrow biopsy. Instead, other pain management strategies that do not affect clotting should be considered.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While anemia is a common finding in aplastic anemia, it is not the most comprehensive answer. Aplastic anemia results in a deficiency of all blood cell types due to bone marrow failure, so while anemia is present, it does not fully capture the extent of the disorder.
B. This is the most accurate choice. Pancytopenia refers to the simultaneous reduction of red blood cells, white blood cells, and platelets. In aplastic anemia, the bone marrow fails to produce adequate blood cells, leading to this triad of cytopenias, making it the hallmark of the disease.
C. Neutropenia, which is a low level of neutrophils (a type of white blood cell), can occur in aplastic anemia. However, it is only one component of the broader condition and does not represent the complete picture of the disease.
D. Leukopenia refers to a low white blood cell count. Like neutropenia, it can be a finding in aplastic anemia, but it does not encompass the anemia and thrombocytopenia that also occur.
Correct Answer is A
Explanation
A. This statement indicates a good understanding of nutritional needs. High-protein foods are essential for maintaining muscle mass and supporting immune function, particularly for individuals with HIV. Finger foods can also help if the client has a reduced appetite or difficulty with larger meals.
B. While hydration is important, 1 liter may not be sufficient for overall health, especially if the client is experiencing weight loss or other symptoms of dehydration. The nurse would typically recommend a higher intake, considering fluid needs can vary based on activity level and overall health.
C. This statement may not be optimal for weight gain. For someone struggling with weight maintenance, smaller, more frequent meals may be more beneficial than three large meals. Large meals might lead to fullness and decrease overall caloric intake, which can hinder weight gain efforts.
D. While fats can provide a high caloric density, a diet excessively high in unhealthy fats is not ideal. It’s important to focus on healthy fats (like avocados, nuts, and olive oil) rather than just increasing fat intake indiscriminately.
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