Chapter 30/31 - Hematologic System

Question 1

12. A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein
    thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level
    drops to 110,000/μL. Which action will the nurse include in the plan of care?
    a. Use low-molecular-weight heparin (LMWH) only.
    b. Administer the warfarin (Coumadin) at the scheduled time.
    c. Teach the patient about the purpose of platelet transfusions.
    d. Discontinue heparin and flush intermittent IV lines using normal saline.

Answer 1

ANS: D
All heparin is discontinued when the HIT is diagnosed. The patient should be
instructed to never receive heparin or LMWH. Warfarin is usually not given until
the platelet count has returned to 150,000/μL. The platelet count does not drop
low enough in HIT for a platelet transfusion, and platelet transfusions increase
the risk for thrombosis.
13. A

Question 2

14. Which intervention will be included in the nursing care plan for a patient
    with immune thrombocytopenic purpura (ITP)?
    a. Assign the patient to a private room.
    b. Avoid intramuscular (IM) injections.
    c. Use rinses rather than a soft toothbrush for oral care.
    d. Restrict activity to passive and active range of motion.

Answer 2

ANS: B
IM or subcutaneous injections should be avoided because of
the risk for bleeding. A soft toothbrush can be used for oral
care. There is no need to restrict activity or place the patient in
a private room.

Question 3

15. Which laboratory result will the nurse expect to show a decreased value if a
    patient develops heparin-induced thrombocytopenia (HIT)?
    a. Prothrombin time
    b. Erythrocyte count
    c. Fibrinogen degradation products
    d. Activated partial thromboplastin time

Answer 3

ANS: D
Platelet aggregation in HIT causes neutralization of heparin, so
that the activated partial thromboplastin time will be shorter
and more heparin will be needed to maintain therapeutic
levels. The other data will not be affected by HIT.

Question 4

16. The nurse caring for a patient with type A hemophilia being admitted to the
    hospital with severe pain and swelling in the right knee will
    a. immobilize the joint.
    b. apply heat to the knee.
    c. assist the patient with light weight bearing.
    d. perform passive range of motion to the knee.

Answer 4

ANS: A
The initial action should be total rest of the knee to minimize bleeding.
Ice packs are used to decrease bleeding. Range of motion (ROM) and
weight-bearing exercise are contraindicated initially, but after the
bleeding stops, ROM and physical therapy are started.

Question 5

17. A 28-year-old man with von Willebrand disease is admitted to the hospital for minor
    knee surgery. The nurse will review the coagulation survey to check the
    a. platelet count.
    b. bleeding time.
    c. thrombin time.
    d. prothrombin time

Answer 5

ANS: B
The bleeding time is affected by von Willebrand
disease. Platelet count, prothrombin time, and
thrombin time are normal in von Willebrand disease

Question 6

A 19-year-old woman with immune thrombocytopenic purpura (ITP) has an order for a
platelet transfusion. Which information indicates that the nurse should consult with the
health care provider before obtaining and administering platelets?
a. The platelet count is 42,000/L.
b. Petechiae are present on the chest.
c. Blood pressure (BP) is 94/56 mm Hg.
d. Blood is oozing from the venipuncture site.

Answer 6

ANS: 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. Therefore the nurse
should clarify the order with the health care provider before giving the
transfusion. The other data all indicate that bleeding caused by ITP may be
occurring and that the platelet transfusion is appropriate

Question 7

20. Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is
    effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy?
    a. Platelet count
    b. Reticulocyte count
    c. Total lymphocyte count
    d. Absolute neutrophil count

Answer 7

ANS: D
Filgrastim increases the neutrophil count and function in neutropenic
patients. Although total lymphocyte, platelet, and reticulocyte counts
also are important to monitor in this patient, the absolute neutrophil
count is used to evaluate the effects of filgrastim.

Question 8

21. A 68-year-old woman with acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be
    worth undergoing. Which response by the nurse is appropriate?
    a. “If you do not want to have chemotherapy, other treatment options include stem cell transplantation.”
    b. “The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy.”
    c. “The decision about treatment is one that you and the doctor need to make rather than asking what I would do.”
    d. “You don’t need to make a decision about treatment right now because leukemias in adults tend to progress quite slowly.”

Answer 8

ANS: B
This response uses therapeutic communication by addressing the patient’s
question and giving accurate information. The other responses either give
inaccurate information or fail to address the patient’s question, which will
discourage the patient from asking the nurse for information

Question 9

22. A patient with a history of a transfusion-related acute lung injury (TRALI) is to receive a
    transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the
    risk for TRALI for this patient?
    a. Infuse the PRBCs slowly over 4 hours.
    b. Transfuse only leukocyte-reduced PRBCs.
    c. Administer the scheduled diuretic before the transfusion.
    d. Give the PRN dose of antihistamine before the transfusion

Answer 9

ANS: B
TRALI is caused by a reaction between the donor and the patient leukocytes
that causes pulmonary inflammation and capillary leaking. The other actions
may help prevent respiratory problems caused by circulatory overload or by
allergic reactions, but they will not prevent TRALI.

Question 10

A 54-year-old woman with acute myelogenous leukemia (AML) is considering
treatment with a hematopoietic stem cell transplant (HSCT). The best approach for the
nurse to assist the patient with a treatment decision is to
a. emphasize the positive outcomes of a bone marrow transplant.
b. discuss the need for adequate insurance to cover post-HSCT care.
c. ask the patient whether there are any questions or concerns about HSCT.
d. explain that a cure is not possible with any other treatment except HSCT

Answer 10

ANS: C
Offering the patient an opportunity to ask questions or discuss concerns about HSCT will
encourage the patient to voice concerns about this treatment and also will allow the nurse
to assess whether the patient needs more information about the procedure. Treatment of
AML using chemotherapy is another option for the patient. It is not appropriate for the
nurse to ask the patient to consider insurance needs in making this decision

Question 11

25. An appropriate nursing intervention for a patient with non-Hodgkin’s
    lymphoma whose platelet count drops to 18,000/μL during chemotherapy is to
    a. check all stools for occult blood.
    b. encourage fluids to 3000 mL/day.
    c. provide oral hygiene every 2 hours.
    d. check the temperature every 4 hours

Answer 11

ANS: A
Because the patient is at risk for spontaneous bleeding, the nurse should check
stools for occult blood. A low platelet count does not require an increased
fluid intake. Oral hygiene is important, but it is not necessary to provide oral
care every 2 hours. The low platelet count does not increase risk for infection,
so frequent temperature monitoring is not indicated.

Question 12

26. A 30-year-old man with 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?
    a. Discuss the need for hospital admission to treat the neutropenia.
    b. Teach the patient to administer filgrastim (Neupogen) injections.
    c. Plan to discontinue the chemotherapy until the neutropenia resolves.
    d. Order a high-efficiency particulate air (HEPA) filter for the patient’s home.

Answer 12

ANS: B
The patient may be taught to self-administer filgrastim injections. Although chemotherapy
may be stopped with severe neutropenia (neutrophil count less than 500/μL),
administration of filgrastim usually allows the chemotherapy to continue. Patients with
neutropenia are at higher risk for infection when exposed to other patients in the hospital.
HEPA filters are expensive and are used in the hospital, where the number of pathogens is
much higher than in the patient’s home environment.

Question 13

27. Which information obtained by the nurse caring for a patient with thrombocytopenia
    should be immediately communicated to the health care provider?
    a. The platelet count is 52,000/μL.
    b. The patient is difficult to arouse.
    c. There are purpura on the oral mucosa.
    d. There are large bruises on the patient’s back.

Answer 13

ANS: B
Difficulty in arousing the patient may indicate a cerebral hemorrhage,
which is life threatening and requires immediate action. The other
information should be documented and reported but would not be
unusual in a patient with thrombocytopenia

Question 14

28. The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to
    a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse
    delegate to unlicensed assistive personnel (UAP)?
    a. Verify the patient identification (ID) according to hospital policy.
    b. Obtain the temperature, blood pressure, and pulse before the transfusion.
    c. Double-check the product numbers on the PRBCs with the patient ID band.
    d. Monitor the patient for shortness of breath or chest pain during the transfusion.

Answer 14

ANS: B
UAP education includes measurement of vital signs. UAP would
report the vital signs to the registered nurse (RN). The other
actions require more education and a larger scope of practice
and should be done by licensed nursing staff members.

Question 15

29. A postoperative patient receiving a transfusion of packed red blood cells develops
    chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After
    stopping the transfusion, what action should the nurse take?
    a. Draw blood for a new crossmatch.
    b. Send a urine specimen to the laboratory.
    c. Administer PRN acetaminophen (Tylenol).
    d. Give the PRN diphenhydramine (Benadryl).

Answer 15

ANS: C
The patient’s clinical manifestations are consistent with a febrile, nonhemolytic transfusion
reaction. The transfusion should be stopped and antipyretics administered for the fever as
ordered. A urine specimen is needed if an acute hemolytic reaction is suspected.
Diphenhydramine (Benadryl) is used for allergic reactions. This type of reaction does not
indicate incorrect crossmatching

Question 16

30. A patient in the emergency department complains of back pain and difficulty breathing
    15 minutes after a transfusion of packed red blood cells is started. The nurse’s first action
    should be to
    a. administer oxygen therapy at a high flow rate.
    b. obtain a urine specimen to send to the laboratory.
    c. notify the health care provider about the symptoms.
    d. disconnect the transfusion and infuse normal saline.

Answer 16

ANS: D
The patient’s symptoms indicate a possible acute hemolytic reaction
caused by the transfusion. The first action should be to disconnect the
transfusion and infuse normal saline. The other actions also are
needed but are not the highest priority

Question 17

A 30-year-old man with 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?
a. Discuss the need for hospital admission to treat the neutropenia.
b. Teach the patient to administer filgrastim (Neupogen) injections.
c. Plan to discontinue the chemotherapy until the neutropenia resolves.
d. Order a high-efficiency particulate air (HEPA) filter for the patient’s home

Answer 17

ANS: B
The patient may be taught to self-administer filgrastim injections. Although chemotherapy
may be stopped with severe neutropenia (neutrophil count less than 500/μL),
administration of filgrastim usually allows the chemotherapy to continue. Patients with
neutropenia are at higher risk for infection when exposed to other patients in the hospital.
HEPA filters are expensive and are used in the hospital, where the number of pathogens is
much higher than in the patient’s home environment

Question 18

33. A 19-year-old woman with immune thrombocytopenic purpura (ITP) has an order for a
    platelet transfusion. Which information indicates that the nurse should consult with the
    health care provider before obtaining and administering platelets?
    a. The platelet count is 42,000/L.
    b. Petechiae are present on the chest.
    c. Blood pressure (BP) is 94/56 mm Hg.
    d. Blood is oozing from the venipuncture site.

Answer 18

ANS: 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. Therefore the nurse
should clarify the order with the health care provider before giving the
transfusion. The other data all indicate that bleeding caused by ITP may be
occurring and that the platelet transfusion is appropriate.

Question 19

34. Which problem reported by a patient with hemophilia is most important for
    the nurse to communicate to the physician?
    a. Leg bruises
    b. Tarry stools
    c. Skin abrasions
    d. Bleeding gums

Answer 19

ANS: B
Melena is a sign of gastrointestinal bleeding and requires collaborative actions
such as checking hemoglobin and hematocrit and administration of coagulation
factors. The other problems indicate a need for patient teaching about how to
avoid injury, but are not indicators of possible serious blood loss

Question 20

35. A patient with septicemia develops prolonged bleeding from venipuncture sites and
    blood in the stools. Which action is most important for the nurse to take?
    a. Avoid venipunctures.
    b. Notify the patient’s physician.
    c. Apply sterile dressings to the sites.
    d. Give prescribed proton-pump inhibitors.

Answer 20

ANS: B
The patient’s new onset of bleeding and diagnosis of sepsis suggest that disseminated
intravascular coagulation (DIC) may have developed, which will require collaborative
actions such as diagnostic testing, blood product administration, and heparin
administration. The other actions also are appropriate, but the most important action
should be to notify the physician so that DIC treatment can be initiated rapidly

Question 21

36. A patient with possible disseminated intravascular coagulation arrives in the
    emergency department with a blood pressure of 82/40, temperature 102° F (38.9° C), and
    severe back pain. Which physician order will the nurse implement first?
    a. Administer morphine sulfate 4 mg IV.
    b. Give acetaminophen (Tylenol) 650 mg.
    c. Infuse normal saline 500 mL over 30 minutes.
    d. Schedule complete blood count and coagulation studies

Answer 21

ANS: C
The patient’s blood pressure indicates hypovolemia caused by blood loss and
should be addressed immediately to improve perfusion to vital organs. The
other actions also are appropriate and should be rapidly implemented, but
improving perfusion is the priority for this patient.

Question 22

43. Following successful treatment of Hodgkin’s lymphoma for a 55-year-old
    woman, which topic will the nurse include in patient teaching?
    a. Potential impact of chemotherapy treatment on fertility
    b. Application of soothing lotions to treat residual pruritus
    c. Use of maintenance chemotherapy to maintain remission
    d. Need for follow-up appointments to screen for malignancy

Answer 22

ANS: D
The chemotherapy used in treating Hodgkin’s lymphoma results in a high incidence of
secondary malignancies; follow-up screening is needed. The fertility of a 55-year-old
woman will not be impacted by chemotherapy. Maintenance chemotherapy is not used for
Hodgkin’s lymphoma. Pruritus is a clinical manifestation of lymphoma, but should not be a
concern after treatment.

Question 23

44. A patient who has non-Hodgkin’s lymphoma is receiving combination treatment with
    rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most
    rapid action by the nurse?
    a. Anorexia
    b. Vomiting
    c. Oral ulcers
    d. Lip swelling

Answer 23

ANS: D
Lip swelling in angioedema may indicate a hypersensitivity reaction to
the rituximab. The nurse should stop the infusion and further assess for
anaphylaxis. The other findings may occur with chemotherapy, but are
not immediately life threatening.

Question 24

A 54-year-old woman with acute myelogenous leukemia (AML) is considering treatment
with a hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist
the patient with a treatment decision is to
a. emphasize the positive outcomes of a bone marrow transplant.
b. discuss the need for adequate insurance to cover post-HSCT care.
c. ask the patient whether there are any questions or concerns about HSCT.
d. explain that a cure is not possible with any other treatment except HSCT

Answer 24

ANS: C
Offering the patient an opportunity to ask questions or discuss concerns about HSCT will
encourage the patient to voice concerns about this treatment and also will allow the nurse
to assess whether the patient needs more information about the procedure. Treatment of
AML using chemotherapy is another option for the patient. It is not appropriate for the
nurse to ask the patient to consider insurance needs in making this decision.

Question 25

A 68-year-old woman with acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be
worth undergoing. Which response by the nurse is appropriate?
a. “If you do not want to have chemotherapy, other treatment options include stem cell transplantation.”
b. “The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy.”
c. “The decision about treatment is one that you and the doctor need to make rather than asking what I would do.”
d. “You don’t need to make a decision about treatment right now because leukemias in adults tend to progress quite slowly.”

Answer 25

ANS: B
This response uses therapeutic communication by addressing the patient’s
question and giving accurate information. The other responses either give
inaccurate information or fail to address the patient’s question, which will
discourage the patient from asking the nurse for information

Question 26

An appropriate nursing intervention for a patient with non-Hodgkin’s lymphoma
whose platelet count drops to 18,000/μL during chemotherapy is to
a. check all stools for occult blood.
b. encourage fluids to 3000 mL/day.
c. provide oral hygiene every 2 hours.
d. check the temperature every 4 hours.

Answer 26

ANS: A
Because the patient is at risk for spontaneous bleeding, the nurse should check
stools for occult blood. A low platelet count does not require an increased
fluid intake. Oral hygiene is important, but it is not necessary to provide oral
care every 2 hours. The low platelet count does not increase risk for infection,
so frequent temperature monitoring is not indicated.

Question 27

Following successful treatment of Hodgkin’s lymphoma for a 55-year-old
woman, which topic will the nurse include in patient teaching?
a. Potential impact of chemotherapy treatment on fertility
b. Application of soothing lotions to treat residual pruritus
c. Use of maintenance chemotherapy to maintain remission
d. Need for follow-up appointments to screen for malignancy

Answer 27

ANS: D
The chemotherapy used in treating Hodgkin’s lymphoma results in a high incidence of
secondary malignancies; follow-up screening is needed. The fertility of a 55-year-old
woman will not be impacted by chemotherapy. Maintenance chemotherapy is not used for
Hodgkin’s lymphoma. Pruritus is a clinical manifestation of lymphoma, but should not be a
concern after treatment.

Question 28

. A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care?

a. Use low-molecular-weight heparin (LMWH) only.
b. Administer the warfarin (Coumadin) at the scheduled time.
c. Teach the patient about the purpose of platelet transfusions.
d. Discontinue heparin and flush intermittent IV lines using normal saline.

Answer 28

ANS: D
All heparin is discontinued when the HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/µL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.

Question 29

Several patients call the outpatient clinic and ask to
make an appointment as soon as possible. Which
patient should the nurse schedule to be seen first?

Answer 29

b. 23-year-old with no previous health problems who has a nontender
lump in the axilla
The patient’s age and presence of a nontender axillary lump suggest
possible lymphoma, which needs rapid diagnosis and treatment

Question 30

A 28-year-old man with von Willebrand disease is admitted to the hospital for minor knee surgery. The nurse will review the coagulation survey to check the

a. platelet count.
b. bleeding time.
c. thrombin time.
d. prothrombin time.

Answer 30

ANS: B
The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease

Question 31

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy?

a. Platelet count
b. Reticulocyte count
c. Total lymphocyte count
d. Absolute neutrophil count

Answer 31

ANS: D
Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts also are important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim

Question 32

Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?

a. 44-year-old with sickle cell anemia who says “my eyes always look sort of yellow”
b. 23-year-old with no previous health problems who has a nontender lump in the axilla
c. 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue
d. 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement

Answer 32

ANS: B
The patient’s age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently