Which nursing intervention(s) should be employed when caring for the bone marrow donor immediately following a bone marrow aspiration? (SELECT ALL THAT APPLY)

Administer aspirin for bone pain

Place the client in high Fowler's position

Apply direct pressure to the puncture site

Assess and document vital signs

Initiate neutropenic precautions

Answer and Explanation

Correct Answer : C,D

A.   Aspirin can increase the risk of bleeding and is typically contraindicated in patients who have undergone procedures like bone marrow aspiration. Instead, acetaminophen may be recommended for pain relief, as it does not have blood-thinning effects.
B.   After a bone marrow aspiration, the donor is typically advised to lie flat or in a comfortable position to minimize discomfort and reduce the risk of bleeding. High Fowler's position may not provide the necessary comfort or support needed post-procedure.
C.   Applying direct pressure to the puncture site is a critical intervention to minimize bleeding and promote clotting at the site of the aspiration. The nurse should apply pressure for a sufficient amount of time as per protocol.
D.   Monitoring vital signs is important after any invasive procedure to detect any complications early, such as bleeding or signs of shock. Documenting vital signs also ensures continuity of care.
E.   This choice is not applicable immediately after bone marrow aspiration for a donor. Neutropenic precautions are typically implemented for patients who have low white blood cell counts due to chemotherapy or other conditions. Bone marrow donors do not require these precautions immediately after donation unless there is a specific concern for infection or a significant drop in white blood cell counts.

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Correct Answer is D

Explanation

A. While pain can occur post-operatively and may be a sign of complications, it is not a direct indicator of bleeding. Pain can result from normal healing, surgical trauma, or other complications, but by itself, it does not specifically point to bleeding at the surgical site.
B. An increased blood pressure might not necessarily indicate bleeding. In some cases, blood pressure may increase due to pain, anxiety, or other factors. However, a significant drop in blood pressure would be more indicative of bleeding, especially in conjunction with other symptoms.
C. A decreased white blood cell count (leukopenia) is not typically associated with bleeding at the surgical site. In fact, following surgery, one might expect the white blood cell count to be normal or slightly elevated due to the body’s response to surgery.
D. This finding is indicative of bleeding at the surgical site. Blood on the pillow would suggest that there is active bleeding that has escaped from the surgical site, which is a significant concern that requires immediate assessment and intervention.

A. respiratory alkalosis. B. metabolic alkalosis. C. respiratory acidosis. D. metabolic acidosis.

Correct Answer is A

Explanation

A. The elevated pH and decreased PaCO2 indicate that the respiratory system is causing alkalosis, typically due to hyperventilation (excessive breathing).
B. Metabolic alkalosis would be indicated by a high pH with a normal or high HCO3. Since the HCO3 level is normal and the PaCO2 is low, this does not fit the picture of metabolic alkalosis.
C. Respiratory acidosis would be characterized by a low pH and an elevated PaCO2 due to inadequate ventilation and accumulation of carbon dioxide. Here, the pH is high, and the PaCO2 is low.
D. Metabolic acidosis would be indicated by a low pH with a low HCO3. In this case, the pH is high, and the HCO3 is normal.

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ABG Value	Normal Range
PH	7.35-7.45
PaCO2	35-45 mm Hg
HCO3-	22-26 mEq/L
Base excess	-2 to +2
PaO2	80-95 mm Hg
SaO2	>95%

Which nursing intervention(s) should be employed when caring for the bone marrow donor immediately following a bone marrow aspiration? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a post-op thyroidectomy patient for bleeding. Which finding would indicate bleeding at the surgical site?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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