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Flashcards in Hematological Disorders Deck (131)
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1

The nurse is caring for clients on an oncology unit. Which neutropenia precautions should be implemented? 1. Hold all venipuncture sites for at least five (5) minutes. 2. Limit fresh fruits and flowers. 3. Place all clients in reverse isolation. 4. Have the client use a soft-bristle toothbrush.

2. Fresh fruits and flowers may carry bacteria or insects on the skin of the fruit or dirt on the flowers and leaves, so they are restricted around clients with low white blood cell counts.

2

The nurse is assessing a client diagnosed with acute myeloid leukemia. Which assessment data support this diagnosis? 1. Fever and infections. 2. Nausea and vomiting. 3. Excessive energy and high platelet counts. 4. Cervical lymph node enlargement and positive acid-fast bacillus.

1. Fever and infection are hallmark symptoms of leukemia. They occur because the bone marrow is unable to produce white blood cells of the number and maturity needed to fight infection.

3

The client diagnosed with leukemia has central nervous system involvement. Which instructions should the nurse teach? 1. Sleep with the head of the bed elevated to prevent increased intracranial pressure. 2. Take an analgesic medication for pain only when the pain becomes severe. 3. Explain that radiation therapy to the head may result in permanent hair loss. 4. Discuss end-of-life decisions prior to cognitive deterioration.

3. Radiation therapy to the head and scalp area is the treatment of choice for central nervous system involvement of any cancer. Radiation therapy has longer-lasting side effects than chemotherapy. If the radiation therapy destroys the hair follicle, the hair will not grow back.

4

The client diagnosed with leukemia is scheduled for a bone marrow transplant. Which interventions should be implemented to prepare the client for this procedure? Select all that apply. 1. Administer high-dose chemotherapy. 2. Teach the client about autologous transfusions. 3. Have the family members’ HLA typed 4. Monitor the complete blood cell count daily. 5. Provide central line care per protocol.

1. All of the bone marrow cells must be destroyed prior to “implanting” the healthy bone marrow. High-dose chemotherapy and full-body irradiation therapy are used to accomplish this. 3. The best bone marrow donor comes from an identical twin; next best comes from a sibling who matches. The most complications occur from a matched unrelated donor (MUD). The client’s body recognizes the marrow as foreign and tries to reject it, resulting in graft-versus-host disease (GVHD). 4. The CBC must be monitored daily to assess for infections, anemia, and thrombocytopenia. 5. Clients will have at lest one multiple-line central venous access. These clients are seriously ill and require multiple transfusions and antibiotics.

5

The client is diagnosed with chronic lymphocytic leukemia (CLL) after routine laboratory tests during a yearly physical. Which is the scientific rationale for the random nature of discovering the illness? 1. CCL is not serious, and clients die from other causes first. 2. There are no symptoms with this form of leukemia. 3. This is a childhood illness and is self-limiting. 4. In early stages of CLL the client may be asymptomatic.

4. In this form of leukemia the cells seem to escape apoptosis (programmed cell death), which results in many thousands of mature cells clogging the body. Because the cells are mature, the client may be asymptomatic in the early stages.

6

The client diagnosed with leukemia is being admitted for an induction course of chemotherapy. Which laboratory values indicate a diagnosis of leukemia? 1. A left shift in the white blood cell count differential. 2. A large number of WBCs that decreases after the administration of antibiotics. 3. An abnormally low hemoglobin (Hgb) and hematocrit (Hct) level. 4. Red blood cells that are larger than normal.

1. A left shift indicates that immature white blood cells are being produced and released into the circulating blood volume. This should be investigated for the malignant process of leukemia.

7

Which medication is contraindicated for a client diagnosed with leukemia? 1. Bactrim, a sulfa antibiotic. 2. Morphine, a narcotic analgesic. 3. Epogen, a biologic response modifier. 4. Gleevec, a genetic blocking agent.

3. Epogen is a biologic response modifier that stimulates the bone marrow to produce red blood cells. The bone marrow is the area of malignancy in leukemia. Stimulating the bone marrow would be generally ineffective for the desired results and would have the potential to stimulate malignant growth.

8

The laboratory results for a male client diagnosed with leukemia include RBC count 2.1 mm 106, WBC 150 mm 103, platelets 22 103, K 3.8 mEq/L, Na 139mEq/L. Based on these results, which interventions should the nurse teach the client? 1. Encourage the client to eat foods high in iron. 2. Instruct the client to use an electric razor when shaving. 3. Discuss the importance of limiting sodium in the diet. 4. Instruct the family to limit visits to once a week.

2. The platelet count of 22 103 indicates a platelet count of 22,000. The definition of thrombocytopenia is a count less than 100,000. This client is at risk for bleeding. Bleeding precautions include decreasing the risk by using soft-bristle toothbrushes and electric razors and holding all venipuncture sites for a minimum of five (5) minutes.

9

The nurse writes a nursing problem of “altered nutrition” for a client diagnosed with leukemia who has received a treatment regimen of chemotherapy and radiation. Which nursing intervention should be implemented? 1. Administer an antidiarrheal medication prior to meals. 2. Monitor the client’s serum albumin levels. 3. Assess for signs and symptoms of infection. 4. Provide skin care to irradiated areas,

2. Serum albumin is a measure of the protein content in the blood that is derived from the foods eaten; albumin monitors nutritional status.

10

The nurse and licensed practical nurse (LPN) are caring for clients on an oncology floor. Which client should not be assigned to the LPN? 1. The client newly diagnosed with chronic lymphocytic leukemia. 2. The client who is four (4) hours post-procedure bone marrow biopsy. 3. The client who received two (2) units of PRBCs on the previous shift. 4. The client who is receiving multiple intravenous piggyback medications.

1. The newly diagnosed client will need to be taught about the disease and about treatment options. The registered nurse cannot delegate teaching to a an LPN.

11

The nurse is completing a care plan for a client diagnosed with leukemia. Which independent problem should be addressed? 1. Infection. 2. Anemia. 3. Nutrition. 4. Grieving.

4. Grieving is an independent problem, and the nurse can assess and treat this problem with or without collaboration.

12

The nurse is caring for a client diagnosed with acute myeloid leukemia. Which assessment data warrant immediate intervention? 1. T 99, P 102, R 22, and BP 132/68. 2. Hyperplasia of the gums. 3. Weakness and fatigue. 4. Pain in the left upper quadrant.

4. Pain is expected, but it is a priority, and pain control measures should be implemented.

13

The client diagnosed with non-Hodgkin’s lymphoma is scheduled for a lymphangiogram. Which information should the nurse teach? 1. The scan will identify any malignancy in the vascular system. 2. Radiopaque dye will be injected between the toes. 3. The test will be done similar to a cardiac angiogram. 4. The test will be completed in about five (5) minutes.

2. Dye is injected between the toes of both feet and then scans are performed in a few hours, at 24 hours, and then possibly once a day for several days.

14

The client asks the nurse, “They say I have cancer. How can they tell if I have Hodgkin’s disease from a biopsy?” The nurse’s answer is based on which scientific rationale? 1. Biopsies are nuclear medicine scans that can detect cancer. 2. A biopsy is a laboratory test that detects cancer cells. 3. It determines which kind of cancer the client has. 4. The HCP takes a small piece out of the tumor and looks at the cells.

4. A biopsy is the removal of cells from a mass and examination of the tissue under a microscope to determine if the cells are cancerous. Reed-Sternberg cells are diagnostic for Hodgkin’s disease. If these cells are not found in the biopsy, the HCP can rebiopsy to make sure the specimen provided the needed sample or, depending on involvement of the tissue, diagnose a non- Hodgkin’s lymphoma.

15

The nurse is admitting a client with rule-out Hodgkin’s lymphoma. When the nurse assesses the client, which data would support this diagnosis? 1. Night sweats and fever without “chills.” 2. Edematous lymph nodes in the groin. 3. Malaise and complaints of an upset stomach. 4. Pain in the neck area after a fatty meal.

1. Clients in late stages of Hodgkin’s disease experience drenching diaphoresis, especially at night; fever without chills; and unintentional weight loss. Early-stage disease is indicated by a painless enlargement of a lymph node on one side of the neck (cervical area). Pruritus is also a common symptom.

16

Which client is at the highest risk for developing a lymphoma? 1. The client diagnosed with chronic lung disease who is taking a steroid. 2. The client diagnosed with breast cancer who has extensive lymph involvement. 3. The client who received a kidney transplant several years ago. 4. The client who has had ureteral stent placements for a neurogenic bladder.

3. Clients who have received a transplant must take immunosuppressive medications to prevent rejection of the organ. This immunosuppression blocks the immune system from protecting the body against cancers and other diseases. There is a high incidence of lymphoma among transplant recipients.

17

The female client recently diagnosed with Hodgkin’s lymphoma asks the nurse about her prognosis. Which is the nurse’s best response? 1. Survival for Hodgkin’s disease is relatively good with standard therapy. 2. Survival depends on becoming involved in an investigational therapy program. 3. Survival is poor, with more than 50% of clients dying within six (6) months. 4. Survival is fine for primary Hodgkin’s, but secondary cancers occur within a year.

1. Up to 90% of clients responds well to standard treatment with chemotherapy and radiation therapy, and those that relapse usually respond to a change of chemotherapy medications. Survival depends on the individual client and the stage of disease at diagnosis.

18

The nurse writes the problem of “grieving” for a client diagnosed with non-Hodgkin’s lymphoma. Which collaborative intervention should be included in the plan of care? 1. Encourage the client to talk about feelings of loss. 2. Arrange for the family to plan a memorable outing. 3. Refer the client to the American Cancer Society’s (ACS) Dialogue group. 4. Have the chaplain visit with the client.

4. Collaborative interventions involve other departments of the health-care facility. A chaplain is a referral that can be made, and the two disciplines should work together to provide the needed interventions

19

Which test is considered diagnostic for Hodgkin’s lymphoma? 1. A magnetic resonance image (MRI) of the chest. 2. A computed tomography (CT) scan of the cervical area. 3. An erythrocyte sedimentation rate (ESR). 4. A biopsy of the cervical lymph nodes.

4. Cancers of all types are definitively diagnosed through biopsy procedures. The pathologist must identify Reed-Sternberg cells for a diagnosis of Hodgkin’s disease

20

Which client should be assigned to the experienced medical-surgical nurse who is in the first week of orientation to the oncology floor? 1. The client diagnosed with non-Hodgkin’s lymphoma who is having daily radiation treatments. 2. The client diagnosed with Hodgkin’s disease who is receiving combination chemotherapy. 3. The client diagnosed with leukemia who has petechiae covering both anterior and posterior body surfaces. 4. The client diagnosed with diffuse histolytic lymphoma who is to receive two (2) units of packed red blood cells.

4. This client is receiving blood. The nurse with experience on a medical-surgical floor should be able to administer blood and blood products.

21

Which information about reproduction should be taught to the 27-year-old female client diagnosed with Hodgkin’s disease? 1. The client’s reproductive ability will be the same after treatment is completed. 2. The client should practice birth control for at least two (2) years following therapy. 3. All clients become sterile from the therapy and should plan to adopt. 4. The therapy will temporarily interfere with the client’s menstrual cycle.

2. The client should be taught to practice birth control during treatment and for at least two (2) years after treatment has ceased. The therapies used to treat the cancer can cause cancer. Antineoplastic medications are carcinogenic, and radiation therapy has proved to be a precursor toleukemia. A developing fetus would be subjected to the internal conditions of the mother.

22

Which clinical manifestation of Stage I non-Hodgkin’s lymphoma would the nurse expect to find when assessing the client? 1. Enlarged lymph tissue anywhere in the body. 2. Tender left upper quadrant. 3. No symptom in this stage. 4. Elevated B cell lymphocytes on the CBC.

3. Stage I lymphoma presents with no symptoms; for this reason, clients are usually not diagnosed until the later stages of lymphoma.

23

The nurse and an unlicensed assistive personnel (UAP) are caring for clients in a bone marrow transplant unit. Which nursing task should the nurse delegate? 1. Take the hourly vital signs on a client receiving blood transfusions. 2. Monitor the infusion of antineoplastic medications. 3. Transcribe the doctor’s orders onto the Medication Administration Record (MAR). 4. Determine the client’s response to the therapy.

1. After the first 15 minutes during which the client tolerates the blood transfusion, it is appropriate to ask the unlicensed nursing assistant to take the vital signs as long as the assistant has been given specific parameters for the vital signs. Any vital sign outside the normal parameters must have an intervention by the nurse.

24

The 33-year-old client diagnosed with Stage IV Hodgkin’s lymphoma is at the five (5)- year remission mark. Which information should the nurse teach the client? 1. Instruct the client to continue scheduled screenings for cancer. 2. Discuss the need for follow-up appointments every five (5) years. 3. Teach the client that the cancer risk is now the same as for the general population. 4. Have the client talk with the family about funeral arrangements.

1. The five (5)-year mark is a time for celebration for clients diagnosed with cancer, but the therapies can cause secondary malignancies and there may be a genetic predisposition for the client to develop cancer. The client should continue to be tested regularly.

25

The nurse is admitting a 24-year-old African American female client with a diagnosis of rule-out anemia. The client has a history of gastric bypass surgery for obesity four (4) years ago. Current assessment findings include height 55 ; weight 75 kg; P 110, R 27, and BP 104/66; pale mucous membranes and dyspnea on exertion. Which type of anemia would the nurse suspect the client has developed? 1. Vitamin B12 deficiency. 2. Folic acid deficiency. 3. Iron deficiency. 4. Sickle cell anemia.

1. The rugae in the stomach produce intrinsic factor, which allows the body to use vitamin B12 from the foods eaten. Gastric bypass surgery reduces the amount of rugae drastically. Clients develop pernicious anemia (vitamin B12 deficiency). Other symptoms of anemia include dizziness and the tachycardia and dyspnea listed in the stem.

26

The client diagnosed with menorrhagia complains to the nurse of feeling listless and tired all the time. Which scientific rationale would explain why these symptoms occur? 1. The pain associated with the menorrhagia does not allow the client to rest. 2. The client’s symptoms are unrelated to the diagnosis of menorrhagia. 3. The client probably has been exposed to a virus that causes chronic fatigue. 4. Menorrhagia has caused the client to have decreased levels of hemoglobin.

4. Menorrhagia is excessive blood loss during menses. If the blood loss is severe, then the client will not have the blood’s oxygencarrying capacity needed for daily activities. The most frequent symptom and complication of anemia is fatigue. It frequently has the greatest impact on the client’s ability to function and quality of life.

27

The nurse writes a diagnosis of altered tissue perfusion for a client diagnosed with anemia. Which interventions should be included in the plan of care? Select all that apply. 1. Monitor the client’s Hb and Hct. 2. Move the client to a room near the nurse’s desk. 3. Limit the client’s dietary intake of green vegetables. 4. Assess the client for numbness and tingling. 5. Allow for rest periods during the day for the client.

1. The nurse should monitor the hemoglobin and hematocrit in all clients diagnosed with anemia. 2. Because decreased oxygenation levels to the brain can cause the client to become confused, a room where the client can be observed frequently—near the nurse’s desk—is a safety issue. 4. Numbness and tingling may occur in anemia as a result of neurological involvement. 5. Fatigue is the number-one presenting symptom of anemia.

28

The client diagnosed with iron-deficiency anemia is prescribed ferrous gluconate orally. Which should the nurse teach the client? 1. Take Imodium, an antidiarrheal, OTC for diarrhea. 2. Limit exercise for several weeks until a tolerance is achieved. 3. The stools may be very dark, and this can mask blood. 4. Eat only red meats and organ meats for protein.

3. The stool will be a dark green–black and can mask the appearance of blood in the stool.

29

The nurse and unlicensed nursing assistant are caring for clients on a medical unit. Which task should the nurse delegate to the unlicensed nursing assistant? 1. Check on the bowel movements of a client diagnosed with melena. 2. Take the vitals signs of a client who received blood the day before. 3. Evaluate the dietary intake of a client who has been noncompliant with eating. 4. Shave the client diagnosed with severe hemolytic anemia.

2. The unlicensed nursing assistant can take the vital signs of a client who is stable; this client received the blood the day before.

30

The client is diagnosed with congestive heart failure and anemia. The HCP ordered a transfusion of two (2) units of packed red blood cells. The unit has 250 mL of red blood cells plus 45 mL of additive. At what rate should the nurse set the IV pump to infuse each unit of packed red blood cells?____________________

74 mL/hour. Pumps are set at an hourly rate. The client in congestive heart failure should receive blood at the slowest possible rate to prevent the client from further complications of fluid volume overload. Each unit of blood must be infused within four (4) hours of initiation of the infusion. 250 mL 45 mL 295 ml 295 mL ÷ 4 73 3/4 mL/hour, which rounded is 74 mL/hour

31

The client is being admitted with folic acid–deficiency anemia. Which would be the most appropriate referral? 1. Alcoholic Anonymous. 2. Leukemia Society of America. 3. A hematologist. 4. A social worker.

1. Most clients diagnosed with folic acid anemia have developed the anemia from chronic alcohol abuse. Alcohol consumption increases the use of folates, and the alcoholic diet is usually deficient in folic acid. A referral to Alcoholics Anonymous would be appropriate.

32

The charge nurse is making assignments on a medical floor. Which client should be assigned to the most experienced nurse? 1. The client diagnosed with iron-deficiency anemia who is prescribed iron supplements. 2. The client diagnosed with pernicious anemia who is receiving vitamin B12 intramuscularly (IM). 3. The client diagnosed with aplastic anemia who has developed pancytopenia. 4. The client diagnosed with renal disease who has a deficiency of erythropoietin.

3. Pancytopenia is a situation that develops in clients diagnosed with aplastic anemia because the bone marrow is not able to produce cells of any kind. The client has anemia, thrombocytopenia, and leukopenia. This client could develop an infection or hemorrhage, go into congestive heart failure, or have a number of other complications develop. This client needs the most experienced nurse.

33

The client diagnosed with anemia begins to complain of dyspnea when ambulating in the hall. Which intervention should the nurse implement first? 1. Apply oxygen via nasal cannula. 2. Get a wheelchair for the client. 3. Assess the client’s lung fields. 4. Assist the client when ambulating in the hall.

2. The client is experiencing dyspnea on exertion, which is common for clients with anemia. The client needs a wheelchair to limit the exertion.

34

The nurse is transcribing the HCP’s order for an iron supplement on the MAR. At which time should the nurse schedule the daily dose? 1. 0900. 2. 1000. 3. 1200. 4. 1630.

2. This is approximately two (2) hours after breakfast and is the correct dosing time for iron to achieve the best effects. Iron preparations should be administered one (1) hour before a meal or two (2) hours after a meal. Iron can cause gastrointestinal upset, but if administered with a meal, absorption can be diminished by as much as 50%.

35

The nurse is discharging a client diagnosed with anemia. Which discharge instruction should the nurse teach? 1. Take the prescribed iron until it is completely gone. 2. Monitor pulse and blood pressure at a local pharmacy weekly. 3. Have a complete blood count checked at the HCP’s office. 4. Perform isometric exercise three (3) times a week.

3. The client should have a complete blood count regularly to determine the status of the anemia.

36

The nurse writes a client problem of “activity intolerance” for a client diagnosed with anemia. Which intervention should the nurse implement? 1. Pace activities according to tolerance. 2. Provide supplements high in iron and vitamins. 3. Administer packed red blood cells. 4. Monitor vital signs every four (4) hours.

1. The client’s problem is activity intolerance, and pacing activities directly affect the diagnosis.

37

The charge nurse in the intensive care unit is making client assignments. Which client should the charge nurse assign to the graduate nurse who has just finished the three (3)-month orientation? 1. The client with an abdominal peritoneal resection who has a colostomy. 2. The client diagnosed with pneumonia who has acute respiratory distress syndrome. 3. The client with a head injury developing disseminated intravascular coagulation. 4. The client admitted with a gunshot wound who has an H&H of 7 and 22.

1. This is a major surgery but has a predictable course with no complications identified in the stem, and a colostomy is expected with this type of surgery. The graduate nurse could be assigned this client.

38

Which client would be most at risk for developing disseminated intravascular coagulation (DIC)? 1. A 35-year-old pregnant client with placenta previa. 2. A 42-year-old client with a pulmonary embolus. 3. A 60-year-old client receiving hemodialysis three (3) days a week. 4. A 78-year-old client diagnosed with septicemia.

4. DIC is a clinical syndrome that develops as a complication of a wide variety of other disorders, with sepsis being the most common cause of DIC.

39

The client admitted with full-thickness burns may be developing DIC. Which signs/ symptoms would support the diagnosis of DIC? 1. Oozing blood from the IV catheter site. 2. Sudden onset of chest pain and frothy sputum. 3. Foul smelling, concentrated urine. 4. A reddened, inflamed central line catheter site.

1. The signs/symptoms of DIC result from clotting and bleeding, ranging from oozing blood to bleeding from every body orifice and into the tissues.

40

Which laboratory result would the nurse expect in the client diagnosed with DIC? 1. A decreased prothrombin time (PT). 2. A low fibrinogen level. 3. An increased platelet count. 4. An increased white blood cell count.

2. The fibrinogen level helps predict bleeding in DIC. As it becomes lower, the risk of bleeding increases.

41

Which collaborative treatment would the nurse anticipate for the client diagnosed with DIC? 1. Administer oral anticoagulants. 2. Prepare for plasmapheresis. 3. Administer frozen plasma. 4. Calculate the intake and output.

3. Fresh frozen plasma and platelet concentrates are administered to restore clotting factors and platelets.

42

The unlicensed nursing assistant asks the primary nurse, “How does someone get hemophilia A?” Which statement would be the primary nurse’s best response? 1. “It is an inherited x-linked recessive disorder.” 2. “There is a deficiency of the clotting factor VIII.” 3. “The person is born with hemophilia A.” 4. “The mother carries the gene and gives it to the son.”

4. This is a true statement and explains exactly how someone gets hemophilia A: the mother passes it to the son.

43

Which sign/symptom should the nurse expect to assess in the client diagnosed with hemophilia A? 1. Epistaxis. 2. Petechiae. 3. Subcutaneous emphysema. 4. Intermittent claudication.

1. Nosebleeds along with hemarthrosis, cutaneous hematoma formation, bleeding gums, hematemesis, occult blood, and hematuria are all signs/symptoms of hemophilia.

44

Which situation might cause the nurse to think that the client has von Willebrand’s disease? 1. The client has had unexplained episodes of hematemesis. 2. The client has microscopic blood in the urine. 3. The client has prolonged bleeding following surgery. 4. The female client developed abruptio placentae.

3. von Willebrand’s disease is a type of hemophilia. The most common hereditary bleeding disorder, it is caused by a deficiency in von Willebrand’s (vW) factor and is often diagnosed after prolonged bleeding following surgery or dental extraction.

45

The client with hemophilia A is experiencing hemarthrosis. Which intervention should the nurse recommend to the client? 1. Alternate aspirin and acetaminophen to help with the pain. 2. Apply cold packs for 24–48 hours to the affected area. 3. Perform active range of motion exercise on the extremity. 4. Put the affected extremity in the dependent position.

2. Hemarthrosis is bleeding into the joint. Applying ice to the area can cause vasoconstriction, which can help decrease bleeding.

46

Which sign would the nurse expect to assess in the client diagnosed with idiopathic thrombocytopenia purpura (ITP)? 1. Petechiae on the anterior chest, arms, and neck. 2. Capillary refill of less than three (3) seconds. 3. An enlarged spleen. 4. Pulse oximeter reading of 95%.

1. ITP is due to bleeding from small vessels and mucous membranes. Petechiae, tiny purple or red spots that appear on the skin as a result of minute hemorrhages within the dermal or submucosal layers, and purpura, hemorrhaging into the tissue beneath the skin and mucous membranes, are the first signs of ITP.

47

The nurse is caring for the following clients. Which client should the nurse assess first? 1. The client whose partial thromboplastin time (PTT) is 38 seconds. 2. The client’s whose hemoglobin is 14 gm/dL and hematocrit is 45%. 3. The client’s whose platelet count is 75,000 per milliliter of blood. 4. The client’s whose red blood cell count is 48 106 mm.

3. A platelet count of less than 100,000 per milliliter of blood indicates thrombocytopenia.

48

Which nursing interventions should the nurse implement when caring for a client diagnosed with hemophilia A? Select all that apply. 1. Instruct the client to use a razor blade to shave. 2. Avoid administering enemas to the client. 3. Encourage participation in noncontact sports. 4. Teach the client how to apply direct pressure if bleeding occurs. 5. Explain the importance of not flossing gums.

2. Enemas, rectal thermometers, and intramuscular injections can pose a risk of tissue and vascular trauma that can precipitate bleeding. 3. Even minor trauma can lead to serious bleeding episodes; safer activities such as swimming or golf should be recommended. 4. Direct pressure occludes bleeding vessels.

49

The client has a hematocrit of 22.3% and a hemoglobin of 7.7 mg/dL. The HCP has ordered two (2) units of packed red blood cells to be transfused. Which interventions should the nurse implement? Select all that apply. 1. Obtain a signed consent. 2. Initiate a 22-gauge IV. 3. Assess the client’s lungs. 4. Check for allergies. 5. Hang a keep-open IV of D5W.

1. The client must give permission to receive blood or blood products because of the nature of potential complications. 3. Because infusing IV fluids can cause a fluid volume overload, the nurse must assess for congestive heart failure. Assessing the lungs includes auscultating for crackles and other signs of left-sided heart failure. Assessing the client for jugular vein distention, peripheral edema, and liver engorgement indicates right-sided failure. 4. Checking for allergies is important prior to administering any medication. Some medications are administered prior to blood administration.

50

The client is admitted to the emergency department after a motor-vehicle accident. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first? 1. Type and cross-match for red blood cells immediately (STAT). 2. Initiate an IV with a #18-gauge needle and hang NS. 3. Have the client sign a consent for an exploratory laparotomy. 4. Notify the significant other of the client’s admission.

2. The first action in a situation in which the nurse suspects the client has a fluid volume loss is to replace the volume as quickly as possible.

51

The nurse is working in a blood bank facility procuring units of blood from donors. Which client would not be a candidate to donate blood? 1. The client who had wisdom teeth removed a week ago. 2. The nursing student who received a measles immunization 2 months ago. 3. The mother with a six (6)-week-old newborn. 4. The client who developed an allergy to aspirin in childhood.

3. The client cannot donate blood for 6 months after a pregnancy because of the nutritional demands on the mother.

52

The client with O+blood is in need of an emergency transfusion but the lab does not have any O+blood available. Which potential unit of blood could be given to the client? 1. The O- unit. 2. The A+ unit. 3. The B+ unit. 4. Any Rh unit.

1. O- (O negative) blood is considered the universal donor because it does not contain the antigens A, B, or Rh. (AB is considered the universal recipient because a person with this blood type has all the antigens on the blood).

53

The client is scheduled to have a total hip replacement in two (2) months and has chosen to prepare for autologous transfusions. Which medication would the nurse to prepare the client? 1. Prednisone, a glucocorticoid. 2. Zithromax, an antibiotic. 3. Ativan, a tranquilizer. 4. Epogen, a biologic response modifier.

4. Epogen or Procrit are forms of erythropoietin, substance in the body that stimulates the bone marrow to produce red blood cells. A client may be prescribed iron preparations to prevent depletion of iron stores and erythropoietin to increase RBC production. A unit of blood can be withdrawn once a week beginning at 6 weeks prior to surgery. No phlebotomy will be done within 72 hours of surgery

54

The client undergoing knee replacement surgery has a “cell-saver” apparatus attached to the knee when he arrives in the post-anesthesia care unit (PACU). Which intervention should the nurse implement to care for this drainage system? 1. Infuse the drainage into the client when a prescribed amount fills the chamber. 2. Attach an hourly drainage collection bag to the unit and discard the drainage. 3. Replace the unit with a continuous passive motion unit and start it on low. 4. Have another nurse verify the unit number prior to reinfusing the blood.

1. A cell saver is a device to catch the blood lost during orthopedic surgeries to reinfuse into the client, rather than giving the client donor blood products. The cells are washed with saline and reinfused through a filter into the client. The salvaged cells cannot be stored and must be used within four (4) hours or discarded because of bacterial growth.

55

Which statement is the scientific rationale for infusing a unit of blood in less than four (4) hours? 1. The blood will coagulate if left out of the refrigerator for longer than four (4) hours. 2. The blood has the potential for bacterial growth if allowed to infuse longer. 3. The blood components begin to break down after four (4) hours. 4. The blood will not be affected; this is a laboratory procedure.

2. Blood is a medium for bacterial growth, and any bacteria contaminating the unit will begin to grow if left outside of a controlled refrigerated temperature for longer than four (4) hours, placing the client at risk for septicemia.

56

The HCP orders two (2) units of blood to be administered over eight (8) hours each for a client diagnosed with heart failure. Which intervention(s) should the nurse take? 1. Call the HCP to question the order because blood must infuse within four (4) hours. 2. Retrieve the blood from the laboratory and run each unit at an eight (8)-hour rate. 3. Notify the lab to split each unit into half units and infuse each half for four (4) hours. 4. Infuse each unit for four (4) hours, the maximum rate for a unit of blood.

3. The correct procedure for administering a unit of blood over eight (8) hours is to have the unit split into halves. Each half unit is treated as a new unit and checked accordingly. This slower administration allows the compromised client, such as one with heart failure, to assimilate the extra fluid volume.

57

The client receiving a unit of PRBCs begins to chill and develops hives. Which action should be the nurse’s first response? 1. Notify the laboratory and health-care provider. 2. Administer the histamine-1 blocker, Benadryl, IV. 3. Assess the client for further complications. 4. Stop the transfusion and change the tubing at the hub.

4. The priority in this situation is to prevent a further reaction if possible. Stopping the transfusion and changing the fluid out at the hub will prevent any more of the transfusion from entering the client’s bloodstream.

58

The nurse and unlicensed nursing assistant are caring for clients on an oncology floor. Which nursing task would be delegated to the unlicensed nursing assistant? 1. Assess the urine output on a client who has had a blood transfusion reaction. 2. Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs. 3. Auscultate the lung sounds of a client prior to a transfusion. 4. Assist a client who received ten (10) units of platelets in brushing teeth.

4. The unlicensed nursing assistant can assist a client to brush the teeth. Instructions about using soft-bristle toothbrushes and the need to report to the nurse any pink or bleeding should be given prior to delegating the procedure.

59

The nurse is caring for clients on a medical floor. After the shift report, which client should be assessed first? 1. The client who is two-thirds of the way through a blood transfusion and has had no complaints of dyspnea or hives. 2. The client diagnosed with leukemia who has a hematocrit of 18% and petechiae covering the body. 3. The client with peptic ulcer disease who called over the intercom to say that he is vomiting blood. 4. The client diagnosed with Crohn’s disease who is complaining of perineal discomfort.

3. This client has a potential for hemorrhage and is reporting blood in the vomitus. This client should be assessed first.

60

The client received two (2) units of packed red blood cells of 250 mL with 63 mL of preservative each during the shift. There was 240 mL of saline remaining in the 500- mL bag when the nurse discarded the blood tubing. How many milliliters of fluid should be documented on the intake and output record?____________________

886 mL of fluid has infused. 250 mL + 63 mL =313 mL per unit. 313 + 313 = 626 ml. 500 mL of saline – 240 mL remaining 260 mL infused 626 mL +260 mL = 886 mL of fluid infused.

61

The student nurse asks the nurse, “What is sickle cell anemia?” Which statement by the nurse would be the best answer to the student’s question? 1. “There is some written material at the desk that will explain the disease.” 2. “It is a congenital disease of the blood in which the blood does not clot.” 3. “The client has decreased synovial fluid that causes joint pain.” 4. “The blood becomes thick when the client is deprived of oxygen.”

4. Sickle cell anemia is a disorder of the red blood cells characterized by abnormally shaped red cells that sickle or clump together, leading to oxygen deprivation and resulting in crisis and severe pain.

62

The client’s nephew has just been diagnosed with sickle cell anemia. The client asks the nurse, “How did my nephew get this disease?” Which statement would be the best response by the nurse? 1. “Sickle cell anemia is an inherited autosomal recessive disease.” 2. “He was born with it and both his parents were carriers of the disease.” 3. “At this time, the cause of sickle cell anemia is unknown.” 4. “Your sister was exposed to a virus while she was pregnant.”

2. This explains the etiology in terms that a layperson could understand. When both parents are carriers of the disease, each pregnancy has a 25% chance of producing a child who has sickle cell anemia.

63

The client diagnosed with sickle cell anemia comes to the emergency department complaining of joint pain throughout the body. The oral temperature is 102.4F and the pulse oximeter reading is 91%. Which action should the emergency room nurse implement first? 1. Request arterial blood gases STAT. 2. Administer oxygen via nasal cannula. 3. Start an IV with an 18-gauge Angiocath. 4. Prepare to administer analgesics as ordered.

2. A pulse oximeter reading of less than 93% indicates hypoxia, which warrants oxygen administration.

64

The client diagnosed with sickle cell anemia is experiencing with a vasoocclusive sickle cell crisis secondary to an infection. Which medical treatment should the nurse anticipate the HCP ordering for the client? 1. Administer meperidine (Demerol) intravenously. 2. Admit the client to a private room and keep in reverse isolation. 3. Infuse D5W 0.33% NS at 150 mL/hr via pump. 4. Insert a 22-French Foley catheter with a urimeter.

3. Increased intravenous fluid reduces the viscosity of blood, thereby preventing further sickling as a result of dehydration.

65

The nurse is assessing an African American client diagnosed with sickle cell crisis. Which assessment data is most pertinent when assessing for cyanosis in clients with dark skin? 1. Assess the client’s oral mucosa. 2. Assess the client’s metatarsals. 3. Assess the client’s capillary refill time. 4. Assess the sclera of the client’s eyes.

1. To assess for cyanosis (blueness) in individuals with dark skin, the oral mucosa and conjunctiva should be assessed because cyanosis cannot be assessed in the lips or fingertips.

66

The client is diagnosed with sickle cell crisis. The nurse is calculating the client’s intake and output (I&O) for the shift. The client had 20 ounces of water, eight (8) ounces of apple juice, three (3) cartons of milk with four (4) ounces each, 1800 mL of IV for the last 12 hours, and a urinary output of 1200. What is the client’s total intake for this shift? ___________________

3000 mL. The key is knowing that 1 ounce is equal to 30 mL. Then, 20 ounces (20 x 30) = 600mL, 8 ounces (8 x 30) =240 mL, 4 ounces (4 x 30) = 120 x 3 cartons = 360 mL for a total of 600 + 240 + 360 = 1200 mL of oral fluids. That, plus 1800 mL of IV, makes the total intake for this shift 3000 mL.

67

The nurse is caring for the female client recovering from a sickle cell crisis. The client tells the nurse that her family is planning a trip this summer to Yellowstone National Park. Which response would be best for the nurse? 1. “That sounds like a wonderful trip to take this summer.” 2. “Have you talked to your doctor about taking the trip?” 3. “You really should not take a trip to areas with high altitudes.” 4. “Why do you want to go to Yellowstone National Park?”

3. High altitudes have decreased oxygen, which could lead to a sickle cell crisis.

68

Which is a potential complication that occurs specifically to a male client diagnosed with sickle cell anemia during a sickle cell crisis? 1. Chest syndrome. 2. Compartment syndrome. 3. Priapism. 4. Hypertensive crisis.

3. This is a term that means painful and constant penile erection that can occur in male clients with SCA during a sickle cell crisis.

69

The nurse is completing discharge teaching for the client diagnosed with a sickle cell crisis. The nurse recommends the client getting the flu and pneumonia vaccines. The client asks, “Why should I take those shots? I hate shots.” Which statement by the nurse is the best response? 1. “These vaccines promote health in clients with chronic illnesses.” 2. “You are susceptible to infections. These shots may help prevent a crisis.” 3. “The vaccines will help your blood from sickling secondary to viruses.” 4. “The doctor wanted to make sure that I discussed the vaccines with you.”

2. An individual with SCA has a reduction in splenic activity from infarcts occurring during crises. This situation progresses to the spleen no longer being able to function and this increases the client’s susceptibility to infection.

70

The client diagnosed with sickle cell anemia asks the nurse, “Should I join the Sickle Cell Foundation? I received some information from the Sickle Cell Foundation. What kind of group is it?” Which statement is the best response by the nurse? 1. “It is a foundation that deals primarily with research for a cure for SCA.” 2. “It provides information on the disease and on support groups in this area.” 3. “I recommend joining any organization that will help deal with your disease.” 4. “The foundation arranges for families that have children with sickle cell to meet.”

2. The Foundation’s mission is to provide information about the disease and about support groups in the area. This information helps decrease the client’s and significant others’ feelings of frustration and helplessness.

71

Which sign/symptom will the nurse expect to assess in the client diagnosed with a vasoocclusive sickle cell crisis? 1. Lordosis. 2. Epistaxis. 3. Hematuria. 4. Petechiae.

3. Vasoocclusive crisis, the most frequent crisis, is characterized by organ infarction, which will result in bloody urine secondary to kidney infarction.

72

The male client with sickle cell anemia comes to the emergency room with a temperature of 101.4F and tells the nurse that he is having a sickle cell crisis. Which diagnostic test should the nurse anticipate the emergency room doctor ordering for the client? 1. Spinal tap. 2. Hemoglobin electrophoresis. 3. Sickle-turbidity test (Sickledex). 4. Blood cultures.

4. The elevated temperature is the first sign of bacteremia. Bacteremia leads to a sickle cell crisis. Therefore, the bacteria must be identified so the appropriate antibiotics can be prescribed to treat the infection. Blood cultures assist in determining the type and source of infection so that it can be treated appropriately.

73

The client is diagnosed with severe iron-deficiency anemia. Which statement is the scientific rationale regarding oral replacement therapy? 1. Iron supplements are well tolerated without side effects. 2. There is no benefit from oral preparations; the best route is IV. 3. Oral iron preparations cause diarrhea if not taken with food. 4. Very little of the iron supplement will be absorbed by the body.

4. At best only about 20%–35% of the medication is absorbed through the gastrointestinal tract (GI) tract.

74

The client’s lab values are RBC 5.5 mm (106), WBC 8.9 mm (103), and platelets 189 mm (103). Which intervention should the nurse implement? 1. Prepare to administer packed red blood cells. 2. Continue to monitor the client. 3. Request an order for Neupogen, a biologic response modifier. 4. Institute bleeding precautions

2. All the lab values are within normal limits. The nurse should continue to monitor the client.

75

The client diagnosed with anemia is admitted to the emergency department with dyspnea, cool pale skin, and diaphoresis. Which assessment data warrant immediate intervention? 1. The vital signs are T 98.6 F, P 116, R 28, and BP 88/62. 2. The client is allergic to multiple antibiotic medications. 3. The client has a history of receiving chemotherapy. 4. ABGs are pH 7.35, PCO2 44, HCO3 22, PaO2 92.

1. The pulse of 116 and BP of 88/62 in addition to the other symptoms indicate the client is in shock. This is an emergency situation.

76

The client diagnosed with anemia has an Hgb of 6.1 g/dL. Which complication should the nurse assess for? 1. Decreased pulmonary functioning. 2. Impaired muscle functioning. 3. Congestive heart failure. 4. Altered gastric secretions.

General complications of severe anemia include heart failure, paresthesias, and confusion. The heart tries to compensate for the lack of oxygen in the tissues by becoming tachycardic. The heart will be able to maintain this compensatory mechanism for only so long and then will show evidence of failure.

77

The nurse writes a diagnosis of “activity intolerance” for a client diagnosed with anemia. Which intervention should the nurse implement? 1. Encourage isometric exercises. 2. Assist the client with ADLs. 3. Provide a high-protein diet. 4. Refer to the physical therapist.

2. The client with activity intolerance will need assistance to perform activities of daily living.

78

The client diagnosed with cancer has been undergoing systemic treatments and has red blood cell deficiency. Which signs and symptoms should the nurse teach the client to manage? 1. Nausea associated with cancer treatment. 2. Shortness of breath and fatigue. 3. Controlling mucositis and diarrhea. 4. The emotional aspects of having cancer.

2. Anemia causes the client to experience dyspnea and fatigue. Teaching the client to pace activities and rest often, to eat a balanced diet, and to cope with changes in lifestyle is needed.

79

The nurse is assisting the HCP with a bone marrow biopsy. Which intervention postprocedure has priority? 1. Apply pressure to site for five (5) to ten (10) minutes. 2. Medicate for pain with morphine slow IVP. 3. Maintain head of bed in a high Fowler’s position. 4. Apply oxygen via nasal cannula at 5 LPM.

1. After a bone marrow biopsy, it is important that the client form a clot to prevent bleeding. The nurse should hold direct pressure on the site for five (5) to ten (10) minutes.

80

The client diagnosed with end-stage renal disease (ESRD) has developed anemia. Which would the nurse anticipate the HCP prescribing for this client? 1. Place the client in reverse isolation. 2. Discontinue treatments until blood count improves. 3. Monitor CBC daily to assess for bleeding. 4. Give client erythropoietin, a biologic response modifier.

4. Erythropoietin is a biologic response modifier produced by the kidneys in response to a low red blood cell count in the body. It stimulates the body to produce more RBCs

81

The nurse is planning the care of a client diagnosed with aplastic anemia. Which interventions should be taught to the client? Select all that apply. 1. Avoid alcohol. 2. Pace activities. 3. Stop smoking. 4. Eat a balanced diet. 5. Use a safety razor.

1. Alcohol consumption interferes with the absorption of nutrients. 2. The client will be short of breath with activity and therefore should pace activities. 4. The client should eat a well-balanced diet to be able to manufacture blood cells.

82

The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain? 1. Frequent aspirin (acetylsalicylic acid) and a nonnarcotic analgesic. 2. Motrin (ibuprofen), an NSAID, PRN. 3. Demerol (meperidine), a narcotic analgesic, every four (4) hours. 4. Morphine, a narcotic analgesic, every two (2) to three (3) hours PRN.

4. Morphine is the drug of choice for a crisis; it does not have a ceiling effect and can be given in large amounts and frequent doses.

83

The client is diagnosed with hereditary spherocytosis. Which treatment/procedure would the nurse prepare the client to receive? 1. Bone marrow transplant. 2. Splenectomy. 3. Frequent blood transfusions. 4. Liver biopsy.

2. Hereditary spherocytosis is a relatively common hemolytic anemia (1:5000 people) characterized by an abnormal permeability of the red blood cell, which permits it to become spherical in shape. The spheres are then destroyed by the spleen. A splenectomy is the treatment of choice.

84

Which is the primary goal of care for a client diagnosed with sickle cell anemia? 1. The client will call the HCP if feeling ill. 2. The client will be compliant with medical regimen. 3. The client will live as normal a life as possible. 4. The client will verbalize understanding of treatments.

3. The primary goal for any client coping with a chronic illness is that the client will be able to maintain as normal a life as possible

85

The client diagnosed with thalassemia, a hereditary anemia, is to receive a transfusion of packed RBCs. The cross-match reveals the presence of antibodies that cannot be cross-matched. Which precaution should the nurse implement when initiating the transfusion? 1. Start the transfusion at 10–15 mL per hour for 15–30 minutes. 2. Re–crossmatch the blood until the antibodies are identified. 3. Have the client sign a permit to receive uncrossmatched blood. 4. Have the unlicensed nursing assistant stay with the client.

1. It can be difficult to cross-match blood when antibodies are present. If imperfectly cross-matched blood must be transfused, the nurse must start the blood very slowly and stay with the client, monitoring frequently for signs of a hemolytic reaction.

86

The client is diagnosed with polycythemia vera. The nurse would prepare to perform which intervention? 1. Type and cross-match for a transfusion. 2. Assess for petechiae and purpura. 3. Perform phlebotomy of 500 mL of blood. 4. Monitor for low hemoglobin and hematocrit.

3. The client has too many red blood cells, which can cause as much damage as too few. The treatment for this disease is to remove the excess blood; 500 mL at a time is removed.

87

The client diagnosed with leukemia has had a bone marrow transplant. The nurse monitors the client’s absolute neutrophil count (ANC). Which is the client’s neutrophil count if the WBCs are 2.2 (103) mm, neutrophils are 25%, and bands are 5%.____________________

660 ANC. To determine the absolute neutrophils count, first the WBC count must be determined: 2.2 multiplied by 1000 (103 ) 2,200. Multiply that by 30 (25% neutrophils 5% bands) to obtain 6600 and divide that by 100 to determine the ANC of 660. The ANC is used to determine a client’s risk of developing an infection.

88

The client is diagnosed with leukemia and has leukocytosis. Which laboratory value would the nurse expect to assess? 1. An elevated hemoglobin. 2. A decreased sedimentation count. 3. A decreased red cell distribution width. 4. An elevated white blood cell count.

4. An elevated white blood cell count is what is being described in the term “leukocytosis”—“ leuko” means “white” and “cyto” refers to “cell.” Leukocytosis is the opposite of leukopenia.

89

The client is placed on neutropenia precautions. Which information should the nurse teach the client? 1. Shave with an electric razor and use a soft toothbrush. 2. Eat plenty of fresh fruits and vegetables. 3. Perform perineal care after every bowel movement 4. Some blood in the urine is not unusual.

3. Perineal care after each bowel movement, preferably with an antimicrobial soap, is performed to reduce bacteria on the skin.

90

The client is diagnosed with chronic myeloid leukemia and leukocytosis. Which signs/symptoms would the nurse expect to find when assessing this client? 1. Frothy sputum and jugular vein distention. 2. Dyspnea and slight confusion 3. Right upper quadrant tenderness and nausea. 4. Increased appetite and weight gain.

2. Clients with leukocytosis may be short of breath and somewhat confused as a result of decreased capillary perfusion to the lung and brain from excessive amounts of WBCs inhibiting blood flow through the capillaries.

91

The client’s CBC indicates an RBC 6.0 (106) mm, Hgb 14.2 g d/L, Hct 42%, and platelets 69 (103) mm. Which intervention should the nurse implement? 1. Teach the client to use a soft-bristle toothbrush. 2. Monitor the client for elevated temperature. 3. Check the client’s blood pressure. 4. Hold venipuncture sites for one (1) minute.

1. The client has a low platelet count (thrombocytopenia) and should be on bleeding precautions, such as using a soft bristle toothbrush

92

The 24-year-old female client is diagnosed with idiopathic thrombocytopenia purpura (ITP). Which question would be important for the nurse to ask during the admission interview? 1. “Do you become short of breath during activity?” 2. “How heavy are your menstrual periods?” 3. “Do you have a history of deep vein thrombosis?” 4. “How often do you have migraine headaches?”

2. Because thrombocytopenia causes bleeding the nurse should assess for any type of bleeding that may be occurring. A young female client would present with excessive menstrual bleeding.

93

The client is diagnosed with hemophilia. Which safety precaution should the nurse encourage? 1. Wear helmets and pads during contact sports. 2. Take antibiotics prior to any dental work. 3. Keep clotting factor VIII on hand at all times. 4. Use ibuprofen, an NSAID, for mild pain.

3. The client must have the clotting factor on hand in case of injury to prevent massive bleeding.

94

The nurse writes a diagnosis of “potential for fluid volume deficit related to bleeding” for a client diagnosed with disseminated intravascular coagulation (DIC). Which would be an appropriate goal for this client? 1. The client’s clot formations will resolve in two (2) days. 2. The saturation of the client’s dressings will be documented. 3. The client will use lemon-glycerin swabs for oral care. 4. The client’s urine output will be 30 mL per hour.

4. The problem is addressing the potential for hemorrhage, and a urine output of greater than 30 mL per hour indicates the kidneys are being adequately perfused and the body is not in shock.

95

The client diagnosed with atrial fibrillation is admitted with warfarin (Coumadin) toxicity. Which HCP order would the nurse anticipate? 1. Protamine sulfate, an anticoagulant antidote. 2. Heparin sodium, an anticoagulant. 3. Lovenox, a low molecular weight anticoagulant. 4. Vitamin K, an anticoagulant agonist.

4. The antidote for warfarin (Coumadin) is vitamin K, vitamin K is an anticoagulant.

96

Fifteen minutes after the nurse has initiated a transfusion of packed red blood cells the client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first? 1. Collect urine for analysis. 2. Notify the lab of the reaction. 3. Administer diphenhydramine, an antihistamine. 4. Stop the transfusion at the hub.

4. Any time the nurse suspects the client is having a reaction to blood or blood products, the nurse should stop the infusion at the spot closest to the client and not allow any more of the blood to enter the client’s body.

97

The HCP has ordered one (1) unit of packed RBCs for the client who is right-handed. Which area would be the best place to insert the intravenous catheter? 1. A 2. B 3. C 4. D

3. The left forearm is the best site to start the IV because it has larger veins that will accommodate an 18-gauge catheter, which should be used when administering blood. This area is less likely to have extravasation because there is no joint movement, and this site is on the client’s nondominant side.

98

The nurse is administering a transfusion of packed red blood cells to a client. Which interventions should the nurse implement? List in order of performance. 1. Start the transfusion slowly. 2. Have the client sign a permit. 3. Assess the IV site for size and patency. 4. Check the blood with another nurse at the bedside. 5. Obtain the blood from the laboratory.

In order of performance: 2, 3, 5, 4, 1 2. The client must give consent prior to receiving blood; therefore this is the first intervention. 3. Blood products should be administered within 30 minutes of obtaining the blood from the laboratory; therefore, the nurse should determine that the IV is patent and the catheter is large enough to administer blood, preferably an 18-gauge catheter, before obtaining the blood. 5. The nurse must then obtain the blood from the laboratory. 4. Blood must be checked by two registered nurses at the bedside to check the client’s crossmatch bracelet with the unit of blood. 1. After all of the previous steps are completed,then the nurse should start the infusion of the blood slowly for the first 15 minutes to determine if the client is going to have a reaction.

99

When assessing a patient's nutritional-metabolic pattern related to hematologic health, what should the nurse do?


1. Inspect the skin for petechiae. 




2. Ask the patient about joint pain. 


3. Assess for vitamin C deficiency.
 


4. Determine if the patient can perform ADLs.
 

 

 

 

 

1. Any changes in the skin's texture or color should be explored when assessing the patient's nutritional-metabolic pattern related to hematologic health. The presence of petechiae or ecchymotic areas could be indicative of hematologic deficiencies related to poor nutritional intake or related causes. The other options are not specific to the nutritional-metabolic pattern related to hematologic health.

100

When assessing laboratory values on a patient admitted with septicemia, what should the nurse expect to find?


 


 


1. Increased platelets 


2. Decreased red blood cells
 


3. Decreased erythrocyte sedimentation rate (ESR)
 

4. Increased bands in the white blood cell (WBC) differential (shift to the left)

 

 

 

4. When infections are severe, such as in septicemia, more granulocytes are released from the bone marrow as a compensatory mechanism. To meet the increased demand, many young, immature polymorphonuclear neutrophils (bands) are released into circulation. WBCs are usually reported in order of maturity (initially with the less mature forms on the left side of a written report). Hence, the term "shift to the left" is used to denote an increase in the number of bands. Thrombocytosis occurs with inflammation and some malignant disorders. Decreased red blood cells indicate anemia. Decreased ESR is not indicative of septicemia.

101

Results of a patient's most recent blood work indicate an elevated neutrophil level. The nurse should recognize that this diagnostic finding most likely suggests which problem?


 


 


1. Hypoxemia 




2. An infection 


3. A risk of hypocoagulation
 


4. An acute thrombotic event 

 

 

2. An increase in the neutrophil count most commonly occurs in response to infection or inflammation. Hypoxemia and coagulation do not directly affect neutrophil production.

102

A 30-year-old patient has undergone a splenectomy as a result of injuries suffered in a motor vehicle accident. Which phenomena are likely to result from the absence of the patient's spleen (select all that apply)?


 


 


1. Impaired fibrinolysis 


2. I

ncreased platelet levels 


3. Increased eosinophil levels
 


4. Fatigue and cold intolerance
 

5. Impaired immunologic function

 

 

 

2. 5. Splenectomy can result in increased platelet levels and impaired immunologic function as a consequence of the loss of storage and immunologic functions of the spleen. Fibrinolysis, fatigue, and cold intolerance are less likely to result from the loss of the spleen since coagulation and oxygenation are not primary responsibilities of the spleen.

103

The nurse is providing care for older adults on a subacute, geriatric medicine unit. What effect is aging likely to have on hematologic function of older adults?


 


 


1. Thrombocytosis 




2. Decreased hemoglobin 


3. Decreased WBC count
 


4. Decreased blood volume
 

 

 

 

 

2. Older adults frequently experience decreased hemoglobin levels as a result of changes in erythropoiesis. Decreased blood volume, decreased WBCs, and alterations in platelet number are not considered to be normal, age-related hematologic changes.

104

A blood type and cross-match has been ordered for a male patient who is experiencing an upper gastrointestinal bleed. The results of the blood work indicate that the patient has type A blood. Which description explains what this means?


 


 


1. The patient can be transfused with type AB blood. 


2. The patient may only receive a type A transfusion.
 

3. The patient has A antigens on his red blood cells (RBCs).

 


4. Antibodies are present on the surface of the patient's RBCs.
 

 

 

 

3. An individual with type A blood has A antigens, not A antibodies, on his RBCs. An AB transfusion would result in agglutination, but he may be transfused with either type A or type O blood.

105

The patient has anemia and has had laboratory tests done to diagnose the cause. Which results should the nurse know indicates a lack of nutrients needed to produce new red blood cells (select all that apply)?


 


 

1. Elevated erythrocyte sedimentation rate (ESR)


2. Increased homocysteine 


3. Decreased reticulocyte count
 

4. Decreased cobalamin (vitamin B12 )

5. Increased methylmalonic acid (MMA)

 

 

 

2. 4. 5. Increased homocysteine and MMA along with decreased cobalamin (vitamin B12) indicate cobalamin deficiency, which is a nutrient needed for RBC production. Decreased reticulocytes indicate low bone marrow activity in producing RBCs, not available nutrients. Elevated ESR is related to an increased inflammatory process, not anemia.

106

In assessing the patient, which abnormal finding should the nurse relate to hemostasis abnormalities?


 


 

1. Pale conjunctiva


2. Purpura 


3. Pruritus
 


4. Weakness
 

 

 

 

 

2. Purpura may occur when platelets or clotting factors are decreased and bleeding into the skin occurs. Pruritus is not related to hemostasis, but to hematologic cancers (e.g., lymphomas, leukemias) or increased bilirubin. Weakness and pale conjunctiva are not related to hemostasis unless a lot of bleeding leads to anemia with low Hgb level.

107

During the admission assessment, the nurse discovers that the patient has used illicit drugs. Related to the hematologic system, what question should the nurse next ask the patient?


 


 


1. "Do you have any blood in your stools?" 




2. "What agent and when did you last use it?" 


3. "Have you had any surgeries causing pain?"
 


4. "Do you have shortness of breath with activity?"
 

 

 

 

 

2. Although all these questions are appropriate related to the hematologic system, the only one related specifically to illicit drug use is asking about what agent and when it was last used. The route and frequency should also be assessed

108

The thrombocytopenic patient has had a bone marrow biopsy taken from the posterior iliac crest. What nursing care is the priority for this patient after this procedure?


 


 


1. Position the patient prone.
 

2. Apply a pressure dressing.

3. Administer analgesic for pain.

 


4. Return metal objects to the patient.
 

 

 

 

2. The sterile pressure dressing is applied after a bone marrow biopsy to ensure hemostasis. If bleeding is present, the patient will lie on the site and may need a rolled towel for additional pressure, thus this patient will not be in the prone position. The analgesic should have been administered preprocedure. Metal objects would be removed for an MRI, not a bone marrow biopsy.

109

When caring for a patient with metastatic cancer, the nurse notes a hemoglobin level of 8.7 g/dL and hematocrit of 26%. What should the nurse place highest priority on initiating interventions to reduce?


 


 


1. Thirst
 

2. Fatigue

 


3. Headache
 

4. Abdominal pain 

 

 

 

2. The patient with a low hemoglobin and hematocrit is anemic and would be most likely to experience fatigue. Fatigue develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation to carry out cellular functions. Thirst, headache, and abdominal pain are not related to anemia.

110

The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which health team member in the nurses' station to assist in checking the unit before administration?


 


 


1. Unit secretary
 


2. A physician's assistant
 

3. Another registered nurse

 


4. An unlicensed assistive personnel
 

 

 

 

3. Before hanging a transfusion, the registered nurse must check the unit with another RN or with a licensed practical (vocational) nurse, depending on agency policy. The unit secretary, physician's assistant, or unlicensed assistive personnel should not be asked.

111

Before starting a transfusion of packed red blood cells for an older anemic patient, the nurse would arrange for a peer to monitor his or her other assigned patients for how many minutes when the nurse begins the transfusion?


 


 


1. 5 




2. 15 


3. 30
 


4. 60
 

 

 

 

 

2. As part of standard procedure, the nurse remains with the patient for the first 15 minutes after starting a blood transfusion. Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing. Monitoring during the transfusion will be every 30 to 60 minutes.

112

When preparing to administer an ordered blood transfusion, which IV solution does the nurse use when priming the blood tubing?


 


 

1. 0.45% sodium chloride


2. Lactated Ringer's 


3. 5% dextrose in water
 

4. 0.9% sodium chloride

 

 

 

4. The blood set should be primed before the transfusion with 0.9% sodium chloride, also known as normal saline. It is also used to flush the blood tubing after the infusion is complete to ensure the patient receives blood that is left in the tubing when the bag is empty. Dextrose and lactated Ringer's solutions cannot be used with blood as they will cause RBC hemolysis.

 

113

The nurse notes a physician's order written at 10:00 AM for two units of packed red blood cells to be administered to a patient who is anemic as a result of chronic blood loss. If the transfusion is picked up at 11:30 AM, the nurse should plan to hang the unit no later than what time?


 


 

1. 3:30 PM


2. 11:45 AM 




3. 12:00 noon 


4. 12:30 PM
 

 

 

 

 

3. The nurse must hang the unit of packed red blood cells within 30 minutes of signing them out from the blood bank.

114

The nurse receives a physician's order to transfuse fresh frozen plasma to a patient suffering from an acute blood loss. Which procedure is most appropriate for infusing this blood product?


 


 


1. Infuse the fresh frozen plasma as rapidly as the patient will tolerate. 


2. Hang the fresh frozen plasma as a piggyback to the primary IV solution.
 


3. Infuse the fresh frozen plasma as a piggyback to a primary solution of normal saline.
 


4. Hang the fresh frozen plasma as a piggyback to a new bag of primary IV solution without KCl.
 

 

 

 

 

1. The fresh frozen plasma should be administered as rapidly as possible and should be used within 24 hours of thawing to avoid a decrease in Factors V and VIII. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion.

115

Before beginning a transfusion of RBCs, which action by the nurse would be of highest priority to avoid an error during this procedure?


 


 


1. Check the identifying information on the unit of blood against the patient's ID bracelet. 


2. Select new primary IV tubing primed with lactated Ringer's solution to use for the transfusion.
 


3. Remain with the patient for 60 minutes after beginning the transfusion to watch for signs of a transfusion reaction.
 


4. Add the blood transfusion as a secondary line to the existing IV and use the IV controller to maintain correct flow.
 

 

 

 

 

1. The patient's identifying information (name, date of birth, medical record number) on the ID bracelet should exactly match the information on the blood bank tag that has been placed on the unit of blood. If any information does not match, the transfusions should not be hung because of possible error and risk to the patient. The transfusion is hung on blood transfusion tubing, not a secondary line, and cannot be hung with lactated Ringer's because it will cause RBC hemolysis. Usually, the patient will need continuous monitoring for 15 minutes after the transfusion is started, as this is the time most transfusion reactions occur. Then the patient should be monitored every 30 to 60 minutes during the administration.

116

The blood bank notifies the nurse that the two units of blood ordered for an anemic patient are ready for pick up. Which action should the nurse take to prevent an adverse effect during this procedure?


 


 


1. Immediately pick up both units of blood from the blood bank. 




2. Infuse the blood slowly for the first 15 minutes of the transfusion. 


3. Regulate the flow rate so that each unit takes at least 4 hours to transfuse.
 


4. Set up the Y-tubing of the blood set with dextrose in water as the flush solution.
 

 

 

 

 

2. Because a transfusion reaction is more likely to occur at the beginning of a transfusion, the nurse should initially infuse the blood at a rate no faster than 2 mL/min and remain with the patient for the first 15 minutes after hanging a unit of blood. Only one unit of blood can be picked up at a time, must be infused within 4 hours, and cannot be hung with dextrose.

117

Which patient is most likely to experience anemia related to an increased destruction of red blood cells?


 


 


1. A 59-year-old man whose alcoholism has precipitated folic acid deficiency 




2. A 23-year-old African American man who has a diagnosis of sickle cell disease 


3. A 30-year-old woman with a history of "heavy periods" accompanied by anemia
 


4. A 3-year-old child whose impaired growth and development is attributable to thalassemi
 

 

 

 

 

2. A result of a sickling episode in sickle cell anemia involves increased hemolysis of the sickled cells. Thalassemias and folic acid deficiencies cause a decrease in erythropoiesis, whereas the anemia related to menstruation is a direct result of blood loss.

118

What will caring for a patient with a diagnosis of polycythemia vera likely require the nurse to do?


 


 


1. Encourage deep breathing and coughing. 




2. Assist with or perform phlebotomy at the bedside. 


3. Teach the patient how to maintain a low-activity lifestyle.
 


4. Perform thorough and regularly scheduled neurologic assessments.
 

 

 

 

 

2. Primary polycythemia vera often requires phlebotomy in order to reduce blood volume. The increased risk of thrombus formation that accompanies the disease requires regular exercises and ambulation. Deep breathing and coughing exercises do not directly address the etiology or common sequelae of polycythemia, and neurologic manifestations are not typical.

119

What nursing intervention should be the priority in the care of a 30-year-old woman who has a diagnosis of immune thrombocytopenic purpura (ITP)?


 


 


1.  Administration of packed red blood cells 




2. Administration of oral or IV corticosteroids 


3. Administration of clotting factors VIII and IX
 


4. Maintenance of reverse isolation and application of standard precautions
 

 

 

 

 

2. Common treatment modalities for ITP include corticosteroid therapy to suppress the phagocytic response of splenic macrophages. Blood transfusions, administration of clotting factors, and reverse isolation are not interventions that are indicated in the care of patients with ITP. Standard precautions are used with all patients.

120

A patient with a diagnosis of hemophilia had a fall down an escalator earlier in the day and is now experiencing bleeding in her left knee joint. What should be the emergency nurse's immediate response to this?


 


 


1.  Immediate transfusion of platelets 




2. Resting the patient's knee to prevent hemarthroses 


3. Assistance with intracapsular injection of corticosteroids
 


4. Range-of-motion exercises to prevent thrombus formation
 

 

 

 

 

2. In patients with hemophilia, joint bleeding requires resting of the joint in order to prevent deformities from hemarthrosis. Clotting factors, not platelets or corticosteroids, are administered. Thrombus formation is not a central concern in a patient with hemophilia.

121

An older patient relates that she has increased fatigue and a headache. The nurse identifies pale skin and glossitis on assessment. In response to these findings, which teaching will be helpful to the patient if she has microcytic, hypochromic anemia?


 


 


1. Take enteric-coated iron with each meal. 


2. Take cobalamin with green leafy vegetables.
 

3. Take the iron with orange juice one hour before meals.

 


4. Decrease the intake of the antiseizure medications to improve.
 

 

 

 

3. With microcytic, hypochromic anemia, there may be an iron, B6, or copper deficiency, thalassemia, or lead poisoning. The iron prescribed should be taken with orange juice one hour before meals as it is best absorbed in an acid environment. Megaloblastic anemias occur with cobalamin (vitamin B12) and folic acid deficiencies. Vitamin B12 may help RBC maturation if the patient has the intrinsic factor in the stomach. Green leafy vegetables provide folic acid for RBC maturation. Antiseizure drugs may contribute to aplastic anemia or folic acid deficiency, but the patient should not stop taking the medications. Changes in medications will be prescribed by the health care provider.

122

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find?


 


 


1. Elevated D-dimers 


2. Elevated fibrinogen
 


3. Reduced prothrombin time (PT)
 


4. Reduced fibrin degradation products (FDPs)
 

 

 

 

 

1. The D-dimer is a specific marker for the degree of fibrinolysis and is elevated with DIC. FDP is elevated as the breakdown products from fibrinogen and fibrin are formed. Fibrinogen and platelets are reduced. PT, PTT, aPTT, and thrombin time are all prolonged.

123

The nurse knows that hemolytic anemia can be caused by which extrinsic factors?


 


 

1. Chronic diseases or medications and chemicals


2. Trauma or splenic sequestration crisis 


3. Abnormal hemoglobin or enzyme deficiency
 

4. Macroangiopathic or microangiopathic factors

 

 

 

4. Macroangiopathic or microangiopathic extrinsic factors lead to acquired hemolytic anemias. Trauma or splenic sequestration crisis can lead to anemia from acute blood loss. Abnormal hemoglobin or enzyme deficiency are intrinsic factors that lead to hereditary hemolytic anemias. Chronic diseases or medications and chemicals can decrease the number of RBC precursors which reduce RBC production

124

A patient who has sickle cell disease has developed cellulitis above the left ankle. What is the nurse's priority for this patient?


 


 


1. Start IV fluids. 




2. Maintain oxygenation. 


3. Maintain distal warmth.
 


4. Check peripheral pulses.
 

 

 

 

 

2. Maintaining oxygenation is a priority as sickling episodes are frequently triggered by low oxygen tension in the blood which is commonly caused by an infection. Antibiotics to treat cellulitis, pain control, and fluids to reduce blood viscosity will also be used, but oxygenation is the priority

125

After the diagnosis of disseminated intravascular coagulation (DIC), what is the first priority of collaborative care?


 


 

1. Administer fresh frozen plasma


2. Administer heparin. 


3. Administer whole blood.
 

4. Treat the causative problem.

 

 

 

4. Treating the underlying cause of DIC will interrupt the abnormal response of the clotting cascade and reverse the DIC. Blood product administration occurs based on the specific component deficiencies and is reserved for patients with life-threatening hemorrhage. Heparin will be administered if the manifestations of thrombosis are present and the benefit of reducing clotting outweighs the risk of further bleeding.

126

The patient with cancer is having chemotherapy treatments and has now developed neutropenia. What care should the nurse expect to provide and teach the patient about (select all that apply)?


 


 

1. Private room with a high-efficiency particulate air (HEPA) filter


2. Strict hand washing 


3. Daily nasal swabs for culture
 


4. Monitor temperature every hour.
 

5. Daily skin care and oral hygiene

 


6. Encourage eating all foods to increase nutrients.
 

 

 

 

1. 2. 5. Strict hand washing and daily skin and oral hygiene must be done with neutropenia, because the patient is predisposed to infection from the normal body flora, other people, and uncooked meats, seafood, eggs, unwashed fruits and vegetables, and fresh flowers or plants. The private room with HEPA filtration reduces the aerosolized pathogens in the patient's room. Blood cultures and antibiotic treatment are used when the patient has a temperature of 100.4° F or more, but temperature is not monitored every hour.

127

A 57-year-old patient has been diagnosed with acute myelogenous leukemia (AML). The nurse explains to the patient that collaborative care will focus on what?


 


 


1. Leukapheresis 




2. Attaining remission 


3. One chemotherapy agent
 


4. Waiting with active supportive care
 

 

 

 

 

2. Attaining remission is the initial goal of collaborative care for leukemia. The methods to do this are decided based on age and cytogenetic analysis. The treatments include leukapheresis or hydroxyurea to reduce the WBC count and risk of leukemia–cell-induced thrombosis. A combination of chemotherapy agents will be used for aggressive treatment to destroy leukemic cells in tissues, peripheral blood, and bone marrow and minimize drug toxicity. In nonsymptomatic patients with chronic lymphocytic leukemia (CLL), waiting may be done to attain remission, but not with AML.

128

A patient will receive a hematopoietic stem cell transplant (HSCT). What is the nurse's priority after the patient receives combination chemotherapy before the transplant?


 


 


1. Prevent patient infection. 


2. Avoid abnormal bleeding.
 


3. Give pneumococcal vaccine.
 


4. Provide companionship while isolated.
 

 

 

 

 

1. After combination chemotherapy for HSCT, the patient's bone marrow is destroyed in preparation to receive the bone marrow graft. Thus the patient is immunosuppressed and is at risk for a life-threatening infection. The priority is preventing infection. Bleeding is not usually a problem. Giving the pneumococcal vaccine at this time should not be done, but should have been done previously. Providing companionship is not the primary role of the nurse, although the patient will need support during the time of isolation.

129

A 22-year-old female patient has been diagnosed with stage 1A Hodgkin's lymphoma. The nurse knows that which chemotherapy regimen is most likely to be prescribed for this patient?


 


 


1. Brentuximab vedotin (Adcetris)
 

2. Two to four cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine

 


3. Four to six cycles of ABVD: doxorubicin (Adriamycin), bleomycin, vinblastine, and dacarbazine
 


4. BEACOPP: bleomycin, etoposide, doxorubicin (Adriamycin), cyclophosphamide, vincristine (Oncovin), procarbazine, and prednisone
 

 

 

 

2. The patient with stage favorable prognosis early-stage Hodgkin's lymphoma will receive two to four cycles of ABVD. The unfavorable prognostic featured (stage 1B) Hodgkin's lymphoma would be treated with four to six cycles of chemotherapy. Advanced-stage Hodgkin's lymphoma is treated more aggressively with more cycles or with BEACOPP. Brentuximab vedotin (Adcetris) is a newer agent that will be used to treat patients who have relapsed or refractory disease.

130

The patient is being treated for non-Hodgkin's lymphoma (NHL). What should the nurse first teach the patient about the treatment?


 


 


1. Skin care that will be needed 


2. Method of obtaining the treatment
 


3. Gastrointestinal tract effects of treatment
 

4. Treatment type and expected side effects

 

 

 

4. The patient should first be taught about the type of treatment and the expected and potential side effects. Nursing care is related to the area affected by the disease and treatment. Skin care will be affected if radiation is used. Not all patients will have gastrointestinal tract effects of NHL or treatment. The method of obtaining treatment will be included in the teaching about the type of treatment.

131

The patient is admitted with hypercalcemia, polyuria, and pain in the pelvis, spine, and ribs with movement. Which hematologic problem is likely to display these manifestations in the patient?


 


 


1. Multiple myeloma 


2. Thrombocytopenia
 


3. Megaloblastic anemia
 


4. Myelodysplastic syndrome
 

 

 

 

 

1. Multiple myeloma typically manifests with skeletal pain and osteoporosis that may cause hypercalcemia, which can result in polyuria, confusion, or cardiac problems. Serum hyperviscosity syndrome can cause renal, cerebral, or pulmonary damage. Thrombocytopenia, megaloblastic anemia, and myelodysplastic syndrome are not characterized by these manifestations.