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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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?
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.
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
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.
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?
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.
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.
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.
In assessing the patient, which abnormal finding should the nurse relate to hemostasis abnormalities?
1. Pale conjunctiva
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.
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
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.
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?
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.
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.
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?
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.