LACHARITY 8 Hematologic Problems Flashcards
A patient who has sickle cell disease is admitted with vaso-occlusive crisis
and reports severe abdominal and flank pain. Which of the analgesic
medications on the pain treatment protocol will be best for the nurse to
administer initially?
1. Ibuprofen 800 mg PO
2. Morphine sulfate 4 mg IV
3. Hydromorphone liquid 5 mg PO
4. Fentanyl 25 mcg/hr transdermal patch
Ans: 2 Guidelines for the management of vaso-occlusive crisis suggest the
rapid use of parenteral opioids for patients who have moderate to severe
pain. The other medications may also be appropriate for the patient as the
crisis resolves but are not the best choice for rapid treatment of severe pain.
Focus: Prioritization.
A patient with sickle cell disease is admitted with splenic sequestration. The
blood pressure is 86/40 mm Hg, and heart rate is 124 beats/min. Which of
these actions will the nurse take first?
1. Complete a head-to-toe assessment.
2. Draw blood for type and cross-match.
3. Infuse normal saline at 250 mL/hr.
4. Ask the patient about vaccination history
Ans: 3 Because the patient is severely hypotensive, correction of hypovolemia
caused by the splenic sequestration is the most urgent action. The other
actions are appropriate because a complete assessment will be needed to plan
care, a transfusion is likely to be needed, and vaccination history is pertinent
for patients with sickle cell disease. However, infusion of saline is the priority
need. Focus: Prioritization; Test Taking Tip: Although thorough assessment
of a newly admitted patient is always needed, when the primary assessment
(focused on airway, breathing, circulation, and disability) indicates a need for
rapid treatment, the treatment should be initiated before proceeding with the
rest of the assessment.
When administering a blood transfusion to a patient, which action can the
nurse delegate to the unlicensed assistive personnel (UAP)?
1. Take the patient’s vital signs before the transfusion is started.
2. Assure that the blood is infused within no more than 4 hours.
3. Ask the patient at frequent intervals about presence of chills or dyspnea.
4. Assist with double-checking the patient’s identification and blood bag
number.
Ans: 1 UAP education and role includes obtaining vital signs, which will be
reported to the RN prior to the initiation of the transfusion. Monitoring for
transfusion reactions, adjusting transfusion rate, and assuring that the blood
type and number are correct require critical thinking and should be done by
the RN. Focus: Delegation.
Which of these patients who have just arrived at the emergency department
should the nurse assess first?
1. Patient who reports several dark, tarry stools and a history of peptic ulcer
disease
2. Patient with hemophilia A who is experiencing thigh swelling after a fall
3. Patient who has pernicious anemia and reports paresthesia of the hands
and feet
4. Patient with thalassemia major who needs a scheduled blood transfusion
Ans: 2 Thigh swelling after an injury in a patient with hemophilia likely
indicates acute bleeding, which can compromise blood flow and nerve
function in the leg and should be treated immediately with the
administration of factor replacement. The other patients also need
assessment, treatment, or both, but the data do not indicate any immediate
threat to life or function. Focus: Prioritization.
A patient with chemotherapy-related neutropenia is receiving filgrastim
injections. Which finding by the nurse is most important to report to the
health care provider?
1. The patient says, “My bones are aching.”
2. The patient’s platelet count is 110,000 mm 3 (110 × 10 9 /L).
3. The patient’s white blood cell count is 39,000 mm 3 (39.0 × 10 9 /L).
4. The patient reports that the medication stings when it is injected.
Ans: 3 Leukocytosis is an adverse effect of filgrastim and indicates a need to
stop the medication or decrease dosage. Bone pain is a common adverse
effect as the bone marrow starts to produce more neutrophils; the patient
should receive analgesics, but the medication will be continued. Stinging
with injection may occur; the nurse should administer the medication more
slowly. The patient’s platelet count is low and should be reported, but the
level of 110,000 mm 3 (110 × 10 9 /L) does not increase risk for spontaneous
bleeding. Focus: Prioritization.
The nurse is reviewing the complete blood count for a patient who has been
admitted for knee arthroscopy. Which value is most important to report to
the health care provider before surgery?
1. Hematocrit of 33% (0.33)
2. Hemoglobin level of 10.9 g/dL (109 g/L)
3. Platelet count of 426,000/mm 3 (426 × 10 9 /L)
4. White blood cell count of 16,000/mm 3 (16 × 10 9 /L)
Ans: 4 Centers for Disease Control and Prevention guidelines for the
prevention of surgical site infections indicate that surgery should be
postponed when there is evidence of a preexisting infection such as an
elevation in white blood cell count. The other values are slightly abnormal
but would not be likely to cause postoperative problems for knee
arthroscopy. Focus: Prioritization.
The nurse is providing orientation for a new RN who is preparing to
administer packed red blood cells (PRBCs) to a patient who had blood loss
during surgery. Which action by the new RN requires that the nurse
intervene immediately?
1. Waiting 20 minutes after obtaining the PRBCs before starting the infusion
2. Starting an IV line for the transfusion using a 22-gauge catheter
3. Priming the transfusion set using 5% dextrose in lactated Ringer’s solution
4. Telling the patient that the PRBCs may cause a serious transfusion reaction
Ans: 3 Normal saline, an isotonic solution, should be used when priming the
IV line to avoid causing hemolysis of red blood cells (RBCs). Ideally, blood
products should be infused as soon as possible after they are obtained;
however, a 20-minute delay would not be unsafe. Large-bore IV catheters are
preferable for blood administration; if a smaller catheter must be used,
normal saline may be used to dilute the RBCs. Although the new RN should
avoid increasing patient anxiety by indicating that a serious transfusion
reaction may occur, this action is not as high a concern as using an
inappropriate fluid for priming the IV tubing. Focus: Prioritization.
A 32-year-old patient with sickle cell anemia is admitted to the hospital
during a sickle cell crisis. Blood pressure is 104/62 mm Hg, oxygen saturation
is 92%, and the patient reports pain at a level 8 (on a scale of 0 to 10). Which
action prescribed by the health care provider will the nurse implement first?
1. Administer morphine sulfate 4 to 8 mg IV.
2. Give oxygen at 4 L/min per nasal cannula.
3. Start an infusion of normal saline at 200 mL/hr.
4. Apply warm packs to painful joints.
Ans: 2 National guidelines for sickle cell crisis indicate that oxygen should be
administered if the oxygen saturation is less than 95%. Hypoxia and
deoxygenation of the blood cells are the most common cause of sickling, so
administration of oxygen is the priority intervention here. Pain control
(including administration of morphine and application of warm packs to
joints) and hydration are also important interventions for this patient and
should be accomplished rapidly. Focus: Prioritization.
These activities are included in the care plan for a 78-year-old patient
admitted to the hospital with anemia caused by possible gastrointestinal
bleeding. Which activity can the nurse delegate to an experienced unlicensed
assistive personnel (UAP)?
1. Obtaining stool specimens for fecal occult blood test (FOBT)
2. Having the patient sign a colonoscopy consent form
3. Giving the prescribed polyethylene glycol electrolyte solution
4. Checking for allergies to contrast dye or shellfish
Ans: 1 An experienced UAP will have been taught how to obtain a stool
specimen for the fecal occult blood test because this is a common screening
test for hospitalized patients. Having the patient sign an informed consent
form should be done by the health care provider who will be performing the
colonoscopy. Administering medications and checking for allergies are
within the scope of practice of licensed nursing staff. Focus: Delegation.
The charge nurse is making the daily assignments on the medical-surgical
unit. Which patient is best assigned to a float RN who has come from the
postanesthesia care unit (PACU)?
1. A 30-year-old patient with thalassemia major who has an order for
subcutaneous infusion of deferoxamine
2. A 43-year-old patient with multiple myeloma who requires discharge
teaching
3. A 52-year-old patient with chronic gastrointestinal bleeding who has
returned to the unit after a colonoscopy
1744. A 65-year-old patient with pernicious anemia who has just been admitted
to the unit
Ans: 3 A nurse who works in the postanesthesia care unit will be familiar
with the monitoring needed for a patient who has just returned from a
procedure such as a colonoscopy, which requires moderate sedation or
monitored anesthesia care (conscious sedation). Care of the other patients
requires staff with more experience with various types of hematologic
disorders and would be better to assign to nursing personnel who regularly
work on the medical-surgical unit. Focus: Assignment.
The nurse is making a room assignment for a newly arrived patient whose
laboratory test results indicate pancytopenia. Which patient will be the best
roommate for the new patient?
1. Patient with digoxin toxicity
2. Patient with viral pneumonia
3. Patient with shingles
4. Patient with cellulitis
Ans: 1 Patients with pancytopenia are at higher risk for infection. The
patient with digoxin toxicity presents the least risk of infecting the new
patient. Viral pneumonia, shingles, and cellulitis are infectious processes.
Focus: Prioritization.
A 67-year-old patient who is receiving chemotherapy for lung cancer is
admitted to the hospital with thrombocytopenia. Which statement made by
the patient when the nurse is obtaining the admission history is of most
concern?
1. “I’ve noticed that I bruise more easily since the chemotherapy started.”
2. “My bowel movements are soft and dark brown.”
3. “I take ibuprofen every day because of my history of osteoarthritis.”
4. “My appetite has decreased since the chemotherapy started.”
Ans: 3 Because nonsteroidal anti-inflammatory drugs (NSAIDs) will
decrease platelet aggregation, patients with thrombocytopenia should not use
ibuprofen routinely. Patient teaching about this should be included in the
care plan. Bruising is consistent with the patient’s admission problem of
thrombocytopenia. Soft, dark brown stools indicate that there is no frank or
occult blood in the bowel movements. Although the patient’s decreased
appetite requires further assessment by the nurse, this is a common
complication of chemotherapy. Focus: Prioritization.
After a car accident, a patient with a medical alert bracelet indicating
hemophilia A is admitted to the emergency department. Which action
prescribed by the health care provider will the nurse implement first?
1. Transport to the radiology department for cervical spine radiography.
2. Transfuse factor VII concentrate.
3. Type and cross-match for 4 units of packed red blood cells (PRBCs).
4. Infuse normal saline at 250 mL/hr.
Ans: 2 When a hemophiliac patient is at high risk for bleeding, the priority
intervention is to maximize the availability of clotting factors. The other
181prescribed actions also should be implemented rapidly but do not have as
high a priority as administering clotting factors. Focus: Prioritization.
The home health nurse is obtaining a history for a patient who has deep vein
thrombosis and is taking warfarin 2 mg/day. Which statement by the patient
is the best indicator that additional teaching about warfarin may be needed?
1. “I have started to eat more healthy foods like green salads and fruit.”
2. “The doctor said that it is important to avoid becoming constipated.”
3. “Warfarin makes me feel a little nauseated unless I take it with food.”
4. “I will need to have some blood testing done once or twice a week.”
Ans: 1 Patients taking warfarin are advised to avoid making sudden dietary
changes because changing the oral intake of foods high in vitamin K (e.g.,
green leafy vegetables and some fruits) will have an impact on the
effectiveness of the medication. The other statements suggest that further
teaching may be indicated, but more assessment for teaching needs is
required first. Focus: Prioritization.
A patient is admitted to the intensive care unit with disseminated
intravascular coagulation (DIC) associated with a gram-negative infection.
Which assessment information has the most immediate implications for the
patient’s care?
1. There is no palpable radial or pedal pulse.
2. The patient reports chest pain.
3. The patient’s oxygen saturation is 87%.
4. There is mottling of the hands and feet.
Ans: 3 Because the decrease in oxygen saturation will have the greatest
immediate effect on all body systems, improvement in oxygenation should be
the priority goal of care. The other data also indicate the need for rapid
intervention, but improvement of oxygenation is the most urgent need.
Focus: Prioritization.
