ATI Perfusion Quizlet

Correct Answer: B

Rationale: The correct answer is B: Platelet count. The platelet count is severely decreased, indicating a risk for spontaneous bleeding, which is a critical condition requiring immediate attention. While heart rate, abdominal pain, and white blood cell count are important, a severely decreased platelet count poses a more imminent threat to the patient's health and requires urgent communication to the healthcare provider. The nurse should prioritize addressing this potentially life-threatening issue to ensure prompt intervention and management.

Correct Answer: C

Rationale: The correct answer is C: Numbness of the extremities. Numbness of the extremities is a common finding in patients with pernicious anemia, which is caused by cobalamin (vitamin B12) deficiency. This deficiency affects the peripheral nervous system, leading to neurological symptoms like numbness and tingling in the extremities. Choices A, B, and D are incorrect: Yellow-tinged sclerae is more indicative of jaundice or liver dysfunction, a shiny smooth tongue is seen in conditions like glossitis, and gum bleeding and tenderness are associated with periodontal disease or vitamin C deficiency, not pernicious anemia.

Correct Answer: D

Rationale: The correct answer is D: 'Wash hands regularly and avoid individuals who are ill.' After a splenectomy, the patient is at an increased risk of infection, particularly from gram-positive bacteria. Proper hand hygiene and avoiding contact with sick individuals are crucial to prevent infections. Choices A, B, and C are incorrect because checking for swollen lymph nodes, watching for excessive bleeding or bruising, and taking iron supplements are not specifically related to the increased infection risk post-splenectomy.

Correct Answer: A

Rationale: The correct answer is A. Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/�L unless the patient is actively bleeding. In this case, with a platelet count of 42,000/�L, the count is not critically low, and the patient is not actively bleeding. Therefore, the nurse should consult with the healthcare provider before giving the transfusion. Choices B, C, and D are incorrect because the presence of petechiae, low blood pressure, and oozing from the venipuncture site are common findings in patients with ITP and do not necessarily require immediate consultation before administering a platelet transfusion.

Correct Answer: B

Rationale: After a bone marrow aspiration, it is important to have the patient lie on the left side for 30 to 60 minutes to decrease the risk of bleeding. Elevating the head of the bed to 45 degrees does not directly address the risk of bleeding. Applying a sterile 2-inch gauze dressing to the site is important for wound care but does not specifically address post-procedural positioning. Using a half-inch sterile gauze to pack the wound is not necessary after a bone marrow aspiration.