Chapter 40: Care of Patients with Hematologic Problems

Hypertension Hypotension Rapid, bounding pulse an older adult receiving a transfusion, hypertension is a sign of overload, low blood pressure is a sign of a transfusion reaction, and a rapid and bounding pulse is a sign of fluid overload. In this scenario, 2 units, or about a liter of fluid, could be problematic

An 82-year-old client with anemia is requested to receive 2 units of whole blood. Which assessment findings cause the nurse to discontinue the transfusion because it is unsafe for the client? (Select all that apply.)

A 42-year-old with sickle cell disease receiving a transfusion of packed red blood cells Because sickle cell disease is commonly diagnosed during childhood, the pediatric nurse will be familiar with the disease and with red blood cell transfusion; therefore, he or she should be assigned to the client with sickle cell disease.

An RN from pediatrics has "floated" to the medical-surgical unit. Which client is assigned to the float nurse?

Reviews all information with another registered nurse With another registered nurse, verify the client by name and number, check blood compatibility, and note expiration time. Human error is the most common cause of ABO incompatibility reactions, even for experienced nurses.

The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper client identification?

Penicillin V (Pen-V K) Prophylactic therapy with twice-daily oral penicillin reduces the incidence of pneumonia and other streptococcal infections and is the correct drug to use.

A 32-year-old client recovering from a sickle cell crisis is to be discharged. The nurse says, "You and all clients with sickle cell disease are at risk for infection because of your decreased spleen function. For this reason, you will most likely be prescribed an antibiotic before discharge." Which drug does the nurse anticipate the health care provider will request?

"I can see you are upset. I can stay here with you a while if you like."

A client admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best?

Folic acid deficiency Malabsorption syndromes such as Crohn's disease leave a client prone to folic acid deficiency.

A client has Crohn's disease. What type of anemia is this client most at risk for developing?

Help the client choose soft foods from the menu. Shave the male client with an electric razor. Use a lift sheet when needed to re-position the client. This client has thrombocytopenia and requires bleeding precautions. These include oral hygiene with a soft-bristled toothbrush or swabs, avoiding rectal trauma, eating soft foods, shaving with an electric razor, and using a lift sheet to re-position the client.

A client has a platelet count of 25,000/mm3. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Calling the Rapid Response Team 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.

A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What action takes priority?

Perform a Hemoccult test on the client's stools. This client has laboratory findings indicative of iron deficiency anemia. The most common cause of this disorder is blood loss, often from the GI tract. The nurse should perform a Hemoccult test on the client's stools.

A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the nurse is best?

Keep the lower extremities warm. During a sickle cell crisis, the tissue distal to the occlusion has decreased blood flow and ischemia, leading to pain. Due to decreased blood flow, the client's legs will be cool or cold. The UAP can attempt to keep the client's legs warm

A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)?

Bence-Jones protein in urine This client has possible multiple myeloma. A positive Bence-Jones protein finding would correlate with this condition.

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?

Unfractionated heparin This client has manifestations of heparin-induced thrombocytopenia

A client has been treated for a deep vein thrombus and today presents to the clinic with petechiae. Laboratory results show a platelet count of 42,000/mm3. The nurse reviews the client's medication list to determine if the client is taking which drug?

Assist the client to make "sick day" plans for household responsibilities. While all options are reasonable choices, the best option is to help the client make sick day plans, as that is more comprehensive and inclusive than the other options, which focus on a single item.

A client has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful?

Placing the client in protective precautions Teaching visitors appropriate hand hygiene Telling visitors not to bring live flowers or plants 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. Limiting protein is not a healthy option and will not promote engraftment.

A client has received a bone marrow transplant and is waiting for engraftment. What actions by the nurse are most appropriate? (Select all that apply.)

"I usually put ice on bumps or bruises." The client should be taught to apply ice to areas of minor trauma.

A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition?

Give the client pain medication if it is time for another dose. 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 should provide it.

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

0.45% normal saline Because clients in sickle cell crisis are often dehydrated, the fluid of choice is a hypotonic solution such as 0.45% normal saline.

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?

Double-checking the client and blood product identification This client 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.

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

Infection The main objective in caring for a newly diagnosed client with leukemia is protection from infection.

A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which potential problem takes priority in the client's nursing care plan?

Stop the transfusion. The client may be experiencing a transfusion reaction; the nurse should stop the transfusion immediately.

A client who is receiving a blood transfusion suddenly exclaims to the nurse, "I don't feel right!" What does the nurse do next?

Taking a set of vital signs and notifying the surgeon While some bloody drainage on a new surgical dressing is expected, a saturated dressing is not. This client is already at high risk of bleeding due to the ITP. The nurse should assess vital signs for shock and notify the surgeon immediately.

A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important?

"Would you like to try some relaxation techniques?" Because most clients with multiple myeloma have local or generalized bone pain, analgesics and alternative approaches for pain management, such as relaxation techniques, are used for pain relief. This also offers the client a choice. Before prescribing additional medication, other avenues should be explored to relieve this client's pain.

A client with multiple myeloma reports bone pain that is unrelieved by analgesics. How does the nurse respond to this client's problem?

White blood cell count: 38,000/mm3 Although individuals with SCD often have elevated white blood cell (WBC) counts, this extreme elevation could indicate leukemia, a complication of taking hydroxyurea. The nurse should report this finding immediately.

A client with sickle cell disease (SCD) takes hydroxyurea (Droxia). The client presents to the clinic reporting an increase in fatigue. What laboratory result should the nurse report immediately?

"Use a soft-bristled toothbrush." Correct Using a soft-bristled toothbrush reduces the risk for bleeding in the client with thrombocytopenia

A client with thrombocytopenia is being discharged. What information does the nurse incorporate into the teaching plan for this client?

"Ask her how she is feeling." "Ask her if she needs anything." "Talk to her as you normally would when you haven't seen her for a long time."

A distant family member arrives to visit a female client recently diagnosed with leukemia. The family member asks the nurse, "What should I say to her?" Which responses does the nurse suggest? (Select all that apply.)

"Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" Determination of the need for oxygen and administration of oxygen should be done by licensed nurses who have the education and scope of practice required to administer it.

A hematology unit is staffed by RNs, LPN/LVNs, and unlicensed assistive personnel (UAP). When the nurse manager is reviewing documentation of staff members, which entry indicates that the staff member needs education about his or her appropriate level of responsibility and client care?

Creatinine: 2.9 mg/dL An elevated creatinine indicates kidney damage, which occurs in SCD.

A nurse caring for a client with sickle cell disease (SCD) reviews the client's laboratory work. Which finding should the nurse report to the provider?

Client who reports shortness of breath 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.

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client should the nurse see first?

Help the client find things to hope for each day of recovery. 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.

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?

Client who had two bloody diarrhea stools this morning The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI) tract and should be assessed first.

A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first?

Assess vital signs more often. Hold other IV fluids running. The older adult needs vital signs monitored as often as every 15 minutes for the duration of the transfusion because 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.

A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations in the usual protocol are necessary for the nurse to implement? (Select all that apply.)

Ensuring informed consent is obtained if required 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.

A nurse is preparing to administer a blood transfusion. What action is most important?

Putting on a pair of gloves To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the blood.

A nurse is preparing to hang a blood transfusion. Which action is most important?

Dehydration Extreme stress High altitudes Pregnancy 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.

A nurse working with clients with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factors should clients be taught to avoid? (Select all that apply.)

"Those WBCs are abnormal and don't provide protection." In leukemia, the WBCs are abnormal and do not provide protection to the client against infection.

A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the client's white blood cell count (WBC) is high. What response by the registered nurse is best?

"The donor's cells are actually attacking the client's cells." 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.

A nursing student is struggling to understand the process of graft-versus-host disease. What explanation by the nurse instructor is best?

Intravenous (IV) hydromorphone (Dilaudid) The client needs IV pain relief, and it should be administered on a routine schedule (i.e., before the client has to request it).

A recently admitted client who is in sickle cell crisis requests "something for pain." What does the nurse administer?

Respiratory rate of 36 breaths/min in a client receiving red blood cells An increased respiratory rate indicates a possible hemolytic transfusion reaction; the nurse should quickly stop the transfusion and assess the client further.

The nurse assesses multiple clients who are receiving transfusions of blood components. Which assessment indicates the need for the nurse's immediate action?

"Do you feel more tired after you get up and go to the bathroom?" Asking about feeling tired after using the bathroom is pertinent to the client's activity and provides a comparison. The specific activity helps the client relate to the question and provide needed answers.

The nurse is assessing the endurance level of a client in a long-term care facility. What question does the nurse ask to get this information?

Provide pain medications as needed.

The nurse is caring for a client who is in sickle cell crisis. What action does the nurse perform first?

Doing activities of daily living (ADLs) using rest periods 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.

The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met?

"Getting an annual 'flu shot' would be dangerous for me." The client with SCD should receive annual influenza and pneumonia vaccinations; this helps prevent the development of these infections, which could cause a sickle cell crisis.

The nurse is educating a group of young women who have sickle cell disease (SCD). Which comment from a class member requires correction?

Verify with another RN all of the data on blood products. All data are checked by two RNs. Human error is the most common cause of ABO incompatibilities in administering blood and blood products.

The nurse is mentoring a recent graduate RN about administering blood and blood products. What does the nurse include in the data?

"The sickle cell trait will be inherited by your children." The children of the client with sickle cell disease will inherit the sickle cell trait, but may not inherit the disease. If both parents have the sickle cell trait, their children could get the disease.

The nurse is reinforcing information about genetic counseling to a client with sickle cell disease who has a healthy spouse. What information does the nurse include?

"Allow others to perform your care during periods of extreme fatigue." "Drink small quantities of protein shakes and nutritional supplements daily." "Provide yourself with four to six small, easy-to-eat meals daily." "Stop activity when shortness of breath or palpitations are present." It is critical to have others help the anemic client who is extremely tired. Although it may be difficult for him or her to ask for help, this practice should be stressed to the client. Drinking small protein or nutritional supplements will help rebuild the client's nutritional status. Having four to six small meals daily is preferred over three large meals; this practice conserves the body's expenditure of energy used in digestion and assimilation of nutrients. Stopping activities when strain on the cardiac or respiratory system is noted is critical.

The nurse is teaching a client with newly diagnosed anemia about conserving energy. What does the nurse tell the client? (Select all that apply.)

Dairy products Dairy products such as milk, cheese, and eggs will provide the vitamin B12 that the client needs.

The nurse is teaching a client with vitamin B12 deficiency anemia about dietary intake. Which type of food does the nurse encourage the client to eat?

Hyperkalemia During transfusion, some cells are damaged. These cells release potassium, thus raising the client's serum potassium level (hyperkalemia). This complication is especially common with packed cells and whole-blood products.

The nurse is transfusing 2 units of packed red blood cells to a postoperative client. What post-transfusion electrolyte imbalance does the nurse want to rule out?

Bone marrow hypoplasia Chemical exposure Down syndrome Ionizing radiation educed production of blood cells in the bone marrow is one of the risk factors for developing leukemia. Exposure to chemicals through medical need or by environmental events can also contribute. Certain genetic factors contribute to the development of leukemia; Down syndrome is one such condition. Radiation therapy for cancer or other exposure to radiation, perhaps through the environment, also contributes.

What are the risk factors for the development of leukemia? (Select all that apply.)

Dyspnea on exertion Fatigue Pallor Tachycardia Difficulty breathing—especially with activity—is common with anemia. Lower levels of hemoglobin carry less O2 to the cells of the body. Fatigue is a classic symptom of anemia; lowered O2 levels contribute to a faster pulse (i.e., cardiac rate) and tend to "wear out" a client's energy. Lowered O2 levels deliver less oxygen to all cells, making clients with anemia pale—especially their ears, nail beds, palms, and conjunctivae and around the mouth.

What are the typical clinical manifestations of anemia? (Select all that apply.)

A 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol) Correct Because clients with aplastic anemia usually have low white blood cell counts that place them at high risk for infection, roommates such as the client with G6PD deficiency anemia should be free from infection or infection risk.

Which client does the nurse assign as a roommate for the client with aplastic anemia?

A 34-year-old client with type O blood Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood that contains antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. Type O is considered the universal donor, but not the universal recipient.

Which client is at greatest risk for having a hemolytic transfusion reaction?

Encouraging the use of an electric shaver The client with thrombocytopenia should be advised to use an electric shaver instead of a razor. Any small cuts or nicks can cause problems because of the prolonged clotting time

Which intervention most effectively protects a client with thrombocytopenia?

Obtain requested cultures. Obtaining cultures to identify the infectious agent correctly is the priority for this client.

The nurse is caring for a client with neutropenia who has a suspected infection. Which intervention does the nurse implement first?

Wheezes or crackles Wheezes or crackles in the neutropenic client may be the first symptom of infection in the lungs.

The nurse is caring for a client with neutropenia. Which clinical manifestation indicates that an infection is present or should be ruled out?

Assess the client for infection. Neutropenic clients often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic clients. The nurse should assess for infection.

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

Frequent and thorough handwashing Prevention and early detection strategies are used to protect the client in sickle cell crisis from infection. Frequent and thorough handwashing is of the utmost importance

The nurse is caring for a client with sickle cell disease. Which action is most effective in reducing the potential for sepsis in this client?

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

An 81-year-old with thrombocytopenia and an increase in abdominal girth An increase in abdominal girth in a client with thrombocytopenia indicates possible hemorrhage; this warrants further assessment immediately.

The nurse assesses the client with which hematologic problem first?

Nosebleed The client with thrombocytopenia has a high risk for bleeding. The nosebleed should be attended to immediately

The nurse is assessing a newly admitted client with thrombocytopenia. Which factor needs immediate intervention?

"After this therapy, I will not need to have any more." Induction therapy is not a cure for leukemia, it is a treatment; therefore, the client needs more education to understand this

The nurse is teaching a client about induction therapy for acute leukemia. Which client statement indicates a need for additional education?

Smoking cigarettes According to the American Cancer Society (ACS), the only proven lifestyle-related risk factor for leukemia is cigarette smoking.

What is the most important environmental risk for developing leukemia?

Obtaining vital signs on a client receiving a blood transfusion

Which would be an appropriate task to delegate to unlicensed assistive personnel (UAP) working on a medical-surgical unit?