Ch. 36 & 37 hemo

Which assessment finding(s) may indicate that a client may be experiencing a blood transfusion reaction? (Select all that apply.) a. Tachycardia b. Fever c. Bronchospasm d. Tachypnea e. Urticaria f. Hypotension

ANS: A, B, C, D, E, F Several types of blood transfusion reactions can occur and cause all of the findings listed.

A client is having a radioisotopic imaging scan. What action by the nurse is most important? -Teach the client about the procedure.

ANS: D The nurse should ensure that teaching is done and the client understands the procedure. Contrast dye is not used, so shellfish/iodine allergies are not related. The client will not be radioactive and does not need radiation precautions. Sedation is not used in this procedure.

A nurse is preparing to administer a blood transfusion. Which action is most important? - Put on a pair of gloves.

ANS: D To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the blood. Documentation is important but not the priority at this point. NPO status and isolation are not needed.

A nurse is preparing to administer a blood transfusion. What action is most important? -Ensure that informed consent is obtained

If the facility requires informed consent for transfusions, this action is most important because it precedes the other actions taken during the transfusion. Correctly identifying the client and blood product is a National Patient Safety Goal, and is the most important action after obtaining informed consent. Ringer's lactate is not used to transfuse blood. The nurse does not need to stay with the client for the duration of the transfusion.

A client presents to the emergency department in sickle cell disease crisis. What intervention by the nurse takes priority? - Administer oxygen.

ANS: A All actions are appropriate, but remembering the ABCs, oxygen would come first. The main problem in a sickle cell crisis is tissue and organ hypoxia, so providing oxygen helps halt the process.

A nurse caring for a client with sickle cell disease (SCD) reviews the client's laboratory test results. Which finding would the nurse report to the primary health care provider? -Creatinine: 2.9 mg/dL (256 mcmol/L)

ANS: A An elevated creatinine indicates kidney damage, which occurs in SCD. A hematocrit level of 30% is an expected finding, as is a slightly elevated white blood cell count due to chronic inflammation. A sodium level of 146 mEq/L (146 mmol/L), although slightly high, is not concerning.

A client is having a bone marrow aspiration and biopsy and is extremely anxious. What action by the nurse is the most appropriate? - Assess the client's fears and coping mechanisms.

ANS: A Assessing the client's specific fears and coping mechanisms helps guide the nurse in providing holistic care that best meets the client's needs. Reassurance will be helpful but is not the best option. Sedation is usually used. The client may or may not be totally asleep during the procedure.

A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best? -. 0.45% normal saline

ANS: A Because clients in sickle cell crisis are often dehydrated, the fluid of choice is a hypotonic solution such as 0.45% normal saline. 0.9% normal saline and lactated Ringer's solution are isotonic. D50 is hypertonic and not used for hydration.

The nurse is teaching a client who has pernicious anemia about necessary dietary changes. Which statement by the client indicates understanding about those changes? -I'll increase animal proteins like fish and meat."

ANS: A Clients who have pernicious anemia have a Vitamin B12 deficiency and need to consume foods high in Vitamin B12, such as animal and plant proteins, citrus fruits, green leafy vegetables, and dairy products. While carbohydrates and fats can provide sources of energy, they do not supply the necessary nutrient to improve anemia.

A client hospitalized with sickle cell disease crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe that the client is drug seeking. When the client requests pain medication, what action by the nurse is best? - Give the client pain medication if it is time for another dose.

ANS: A Clients with sickle cell crisis often have severe pain that is managed with up to 48 hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If the client can receive another dose of medication, the nurse would provide it. The other options are judgmental and do not address the client's pain. Giving a placebo is unethical.

The nurse is caring for a patient with leukemia who has severe fatigue. What action by the client best indicates that an important outcome to manage this problem has been met? - Doing activities of daily living (ADLs) using rest periods

ANS: A Fatigue is a common problem for clients with leukemia. This client is managing his or her own ADLs using rest periods, which indicates an understanding of fatigue and how to control it. Helping to plan an activity schedule is a lesser indicator. Requesting a sleeping pill does not help control fatigue during the day. Asking visitors to leave when tired is another lesser indicator. Managing ADLs using rest periods demonstrates the most comprehensive management strategy.

A nurse is caring for four clients with leukemia. After hand-off report, which client would the nurse assess first? -Client who had two bloody diarrhea stools this morning.

ANS: A The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI) tract and should be assessed first to monitor for or avoid the client from going into hypovolemic shock. The client with the slight change in respiratory rate may have an infection or worsening anemia and should be seen next. If the client's respiratory rate was greater than 28 to 30 breaths/min, the client may need the initial assessment. Marked tachypnea is an early sign of a deteriorating client condition. The other two clients are not a priority at this time.

A client has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. What test result would the nurse correlate to this condition? - Bence-Jones protein in urine

ANS: A This client has possible multiple myeloma. A positive Bence-Jones protein finding would correlate with this condition. The Epstein-Barr virus is a herpesvirus that causes infectious mononucleosis and some cancers. A hemoglobin of 18 mg/dL (180 mmol/L) is slightly high for a male and somewhat high for a female; this can be caused by several conditions, and further information would be needed to correlate this value with a specific medical condition. A red blood cell count of 8.2 million/mcL (8.2 × 1012/L) is also high, but again, more information would be needed to correlate this finding with a specific medical condition.

A nurse is assessing a dark-skinned client for pallor. What nursing assessment is best to assess for pallor in this client? - Assess the conjunctiva of the eye.

ANS: A To assess pallor in dark-skinned people, assess the conjunctiva of the eye or the mucous membranes. Looking at the roof of the mouth can reveal jaundice. Opening the hand widely is not related to pallor, nor is palpating for mild swelling.

A client has a platelet count of 9000/mm3 (9 × 109/L). The nurse finds the client confused and mumbling. What nursing action takes priority at this time? - Call the Rapid Response Team.

ANS: A With a platelet count this low, the client is at high risk of spontaneous bleeding. The most disastrous complication would be intracranial bleeding. The nurse needs to call the Rapid Response Team as this client has manifestations of a sudden neurologic change. Bleeding precautions will not address the immediate situation. Placing the client on bedrest is important, but the critical action is to call for immediate medical attention.

The nurse is assessing a client with chronic leukemia. Which laboratory test result(s) is (are) expected for this client? (Select all that apply.) - Decreased hematocrit -. Abnormal white blood cell count -. Low platelet count - Decreased hemoglobin

ANS: A, B, C, D Chronic leukemia affects all types of blood cells causing a decrease is red blood cells (RBCs) and platelets. When the number of RBCs decreases, the client's hemoglobin and hematocrit also decrease. White blood cell counts are also abnormal depending on disease progression and management.

The nurse is caring for a client being treated for Hodgkin lymphoma. For which side effect(s) of treatment will the nurse assess? (Select all that apply.) - Severe nausea and vomiting - Low platelet count -. Skin irritation at radiation site - Low red blood cell count

ANS: A, B, C, D Drug and radiation therapy for Hodgkin lymphoma cause many side and adverse effects, including all of the choices except for a high white blood cell (WBC) count. Instead, most clients experience a low WBC count making them very susceptible to infections.

The nurse is preparing to administer a blood transfusion. Which action(s) by the nurse is (are) most appropriate? (Select all that apply.) - Hang the blood product using normal saline and a filtered tubing set. - Take a full set of vital signs prior to starting the blood transfusion. - Use gloves to start the client's IV if needed and to handle the blood product.

ANS: A, B, D Correct actions prior to beginning a blood transfusion include hanging the product with saline and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using gloves. Someone stays with the client for the first 15 to 20 minutes of the transfusion. Two registered nurses must verify the client's identity and blood compatibility.

The nurse is caring for a client receiving a unit of whole blood. Which nursing action(s) is (are) appropriate regarding infusion administration. (Select all that apply.) - Use a dedicated filtered blood administration set. - Stay with the client for the first 15 to 20 minutes of the infusion. - Monitor and document vital signs per agency policy. - Infuse the transfusion with intravenous normal saline.

ANS: A, B, D, F Blood administration requires a dedicated and filtered intravenous set and a larger catheter or needle due to the viscosity of the infusion. Normal saline is the only IV fluid that is compatible with blood. Vital signs are frequently monitored and documented while the client is carefully assesses for signs and symptoms of a blood transfusion reaction, usually within the first 15 to 20 minutes. One unit of blood is administered in no less than 60 minutes.

A nurse is caring for an older adult receiving multiple packed red blood cell transfusions. Which assessment finding(s) indicate(s) possible transfusion circulatory overload? (Select all that apply.) - Acute confusion - Dyspnea - Hypertension - Bounding pulse

ANS: A, B, D, F Circulatory overload is the result of excessive body fluid which can cause signs and symptoms of heart failure including dyspnea, increased blood pressure, tachycardia (not bradycardia), and a bounding pulse. Dyspnea is caused by hypoxia which in older adults can cause acute confusion. Depression is not a common finding resulting from fluid overload.

A nurse is preparing to administer a packed red blood cell transfusion to an older adult. Understanding age-related changes, what alteration(s) in the usual protocol is (are) necessary for the nurse to implement? (Select all that apply.) - Assess vital signs at least every 15 minutes. - Avoid giving other IV fluids. -Assess the client for fluid overload.

ANS: A, B, F The older adult needs vital signs monitored as often as every 15 minutes for the duration of the transfusion because vital sign changes may be the only indication of a transfusion-related problem. To prevent fluid overload, the nurse obtains a prescription to hold other running IV fluids during the transfusion and assesses the client frequently for signs and symptoms of overload. The other options are not correct.

An older client asks the nurse why "people my age" have weaker immune systems than younger people. What responses by the nurse are best? (Select all that apply.) - Bone marrow produces fewer blood cells as you age." - You have lower levels of plasma proteins in the blood."

ANS: A, C The aging adult has bone marrow that produces fewer cells and decreased blood volume with fewer plasma proteins. Platelet numbers remain unchanged, lymphocytes become less reactive, and spleen function stays the same.

A nurse working with clients diagnosed with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factor(s) should clients be taught to avoid? (Select all that apply.) -. Dehydration -. Extreme stress - High altitudes -. Pregnancy

ANS: A, C, D, E Several factors cause red blood cells to sickle in SCD, including dehydration, extreme stress, high altitudes, and pregnancy. Strenuous exercise can also cause sickling, but not unless it is very vigorous.

Which risk factor(s) places a client at risk for leukemia? (Select all that apply.) - Chemical exposure -. Ionizing radiation exposure -. Viral infections

ANS: A, C, E Chemical and ionizing radiation exposure and viral infections are known risk factors for developing leukemia. Eating genetically modified food and receiving vaccinations are not known risk factors.

While taking a client history, which factor(s) that place the client at risk for a hematologic health problem will the nurse document? (Select all that apply.) - Family history of bleeding problems - Excessive alcohol consumption - Diet high in Vitamin K

ANS: A, C, F A family history of bleeding problems places the client at risk for having a similar problem. Excessive alcohol can damage the liver where prothrombin is produced. A diet high in Vitamin K can cause excessive clotting because it is a major clotting factor.

Which statement(s) about blood transfusion compatibilities is (are) correct? (Select all that apply.) - Donor blood type A can donate to recipient blood type AB. - Donor blood type O can donate to anyone.

ANS: A, D Blood type A can be donated to people who have blood types A or AB. Blood type O can be given to anyone. Blood type B can be donated to people who have blood types B or AB. Blood type AB can only go to recipients with blood type AB.

A client is having a bone marrow aspiration and biopsy. What action by the nurse takes priority? -Ensure that valid consent is in the medical record.

ANS: B A bone marrow aspiration and biopsy is an invasive procedure that requires informed consent. Pain medication and sedation are important components of care for this client but do not take priority. The client may or may not need or be able to shower.

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client would the nurse assess first? - Client who reports shortness of breath

ANS: B Clients with polycythemia vera often have clotting abnormalities due to the hyperviscous blood with sluggish flow. The client reporting shortness of breath may have a pulmonary embolism and should be seen first. The client with a swollen calf may have a deep vein thrombosis and should be seen next. High blood pressure and gout symptoms are common findings with this disorder.

The family of a neutropenic client reports that the client "is not acting right." What action by the nurse is the priority? - Assess the client for infection.

ANS: B Neutropenic clients often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic clients. The nurse would definitely assess for infection. The nurse would assess for pain but this is not the priority.

The nurse is assessing a client who has probable lymphoma. What is the most common early assessment finding for clients with this disorder? -. Enlarged painless lymph node(s)

ANS: B The first change that is noted for clients with probable lymphoma is one or more enlarged lymph nodes. The other findings are either not common in clients with lymphoma or later findings.

The nurse is assessing an older client for any potential hematologic health problem. Which assessment finding is the most significant and would be reported to the primary health care provider? - Multiple petechiae and large bruises

ANS: B The presence of multiple petechiae and large bruises indicate a possible problem with blood clotting. Older adults typically have poor skin turgor and dry, flaky skin due to decreased body fluid as a result of aging. They also lose body hair or have thinning hair as a normal change of aging.

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important? -Double-check the client and blood product identification.

ANS: B This client most likely had a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the client and blood type. Documentation occurs after the client is stable. Bedrest may or may not be needed. Allergies to medications or environmental items are not related.

A nurse works in a gerontology clinic. What age-related change(s) related to the hematologic system will the nurse expect during health assessment? (Select all that apply.) - Nail beds may be thickened or discolored. - Progressive loss or thinning of hair occurs.

ANS: B, C Common findings in older adults include thickened or discolored nail beds, dry (not oily) skin, and thinning hair. The nurse adapts to these changes by altering assessment techniques. Having more dental caries and changes in the sclerae are not normal age-related changes.

The nurse is assessing a client experiencing anemia. Which laboratory findings will the nurse expect for this client? (Select all that apply.) -. Decreased red blood cell count -. Decreased serum iron - Decreased hemoglobin

ANS: B, C, D Clients experiencing anemia have a decreased red blood cell count which leads to a decreased hemoglobin and hematocrit. For some clients, serum iron levels are also decreased. Anemia is not a problem involving platelets or white blood cells.

A nurse is caring for four clients. After reviewing today's laboratory results, which client would the nurse assess first? -.Client with a prothrombin time (PT) of 28 seconds

ANS: C A normal PT is 11 to 12.5 seconds. This client is at high risk of bleeding with a PT of 28 seconds. The other values are within normal limits.

A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority? - Sperm banking

ANS: C All teaching topics are important to the client with lymphoma, but for a young male, sperm banking is of particular concern if the client is going to have radiation to the lower abdomen or pelvis.

A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best? - Help the client find things to hope for each day of recovery.

ANS: C Providing hope is an essential nursing function during treatment for any disease process, but especially during the recovery period after bone marrow transplantation, which can take up to 3 weeks. The nurse can help the client look ahead to the recovery period and identify things to hope for during this time. Visitors are important to clients, but may pose an infection risk. Telling the client that the recovery period must be endured does not acknowledge his or her feelings. Diversionary activities are important, but not as important as instilling hope.

What is the nurse's priority when caring for a client who just completed a bone marrow aspiration and biopsy? -Check the pressure dressing frequently for signs of excessive or active bleeding.

ANS: C The client having a bone marrow aspiration and biopsy has a puncture wound from the large needle used to extract the bone marrow. Therefore, the client is at risk for bleeding. A NSAID should not be given because it can cause bleeding. Avoiding activity helps to prevent bleeding, not infection, and reporting the results of the biopsy is not the responsibility of the nurse.

A client has thrombocytopenia. What statement indicates that the client understands self-management of this condition? -I usually put ice on bumps or bruises."

ANS: C The client should be taught to apply ice to areas of minor trauma. Flossing is not recommended. Hard foods should be avoided. The client should wear well-fitting shoes when ambulating.

The nurse is assessing a client in sickle cell disease (SCD) crisis. What priority client problem will the nurse expect? -. Pain

ANS: C The priority expected client problem for clients experiencing sickle cell disease crisis is pain, often concentrated in the legs, arms, and joints. Clients may also be fatigued and pale but these symptoms are not a priority for care. Infection is not expected but can occur in clients who have SCD crisis.

A client with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this client? - Zoledronic acid

ANS: D All the options are drugs used to treat multiple myeloma, but the drug used specifically for bone manifestations is zoledronic acid, which is a bisphosphonate. This drug class inhibits bone resorption and is used to treat osteoporosis as well.

The nurse is caring for a client experiencing sickle cell disease crisis. Which priority action would help prevent infection? - Performing frequent handwashing

ANS: D Frequent and thorough handwashing is the most important intervention that helps prevent infection. Antibiotics are not usually used to prevent infection. Monitoring the client's temperature or white blood cell count helps to detect the presence of infection, but prevent it.

A client asks about the process of graft-versus-host disease. What explanation by the nurse is correct? -The donor's cells are actually attacking the patient's cells."

ANS: D Graft-versus-host disease is an autoimmune-type process in which the donor cells recognize the client's cells as foreign and begin attacking them. The other answers are not accurate.

An assistive personnel is caring for a client with leukemia and asks why the client is still at risk for infection when the white blood cell count (WBC) is high. What response by the nurse is correct? -Those WBCs are abnormal and don't provide protection."

ANS: D In leukemia, the WBCs are abnormal and do not provide protection to the client against infection. The other statements are not accurate.

Which statement by a client with leukemia indicates a need for further teaching by the nurse? -I will take a daily laxative to prevent constipation."

ANS: D The client experiencing leukemia needs to prevent injury to prevent bleeding, including avoiding hard-bristled toothbrushes, floss, aspirin, and straight or manual safety razors. However, although constipation can cause hemorrhoids or rectal bleeding, laxatives can cause fluid and electrolyte imbalances and abdominal cramping. Stool softeners would be a better option to allow the passage of soft stool.

A hospitalized client has a platelet count of 58,000/mm3 (58 109/L). What action by the nurse is most appropriate? - Place the client on safety precautions.

ANS: D With a platelet count between 40,000 and 80,000/mm3 (40 and 80 109/L), clients are at risk of prolonged bleeding even after minor trauma. The nurse would place the client on safety or bleeding precautions as the most appropriate action. High-protein foods, while healthy, are not the priority. Neutropenic precautions are not needed as the patient's white blood cell count is not low. Limiting visitors would also be more likely related to a low white blood cell count.

A client has received a bone marrow transplant and is waiting for engraftment. What action(s) by the nurse are most appropriate? (Select all that apply.) - Placing the client in protective precautions -. Teaching visitors appropriate hand hygiene -. Telling visitors not to bring live flowers or plants

C,D,E The client waiting for engraftment after bone marrow transplant has no white cells to protect him or her against infection. The client is on protective precautions and visitors are taught hand hygiene. No fresh flowers or plants are allowed due to the standing water in the vase or container that may harbor organisms; clients are also told not to work with houseplants in the home. Limiting protein is not a healthy option and will not promote engraftment.