Hinkle, Ch. 28: Assessment of Hematologic Function & Treatment Modalities

The nurse should be alert to which adverse assessment finding when transfusing a unit of packed red blood cells (PRBCs) too rapidly?

Crackles auscultated bilaterally Increasing the flow rate of a blood transfusion too rapidly can result in circulatory overload. Fluid overload can be manifested by crackles in the lungs. A decreased respiratory rate and decreased temperature are not manifestations of fluid overload. Pain and tenderness in the calf area may indicate a thrombosis which is not as common a manifestation as fluid overload. p. 903

Post transfusion, the donor stands up immediately after the needle is withdrawn. The nurse should be alert for which vital sign change?

Decreased blood pressure. Because of the loss of blood volume, hypotension and syncope may occur when the donor assumes an erect position. The most likely vital sign change is decreased blood pressure. The respiratory rate and temperature should not be affected by a change in position. With hypotension and decreased blood volume, the pulse would increase, not decrease. p. 899

The body responds to infection by increasing the production of white blood cells (WBCs). The nurse should evaluate the differential count for what type of WBCs, which are the first WBCs to respond to an inflammatory event?

Neutrophils Neutrophils, the most abundant type of white blood cell, are the first of the WBCs to respond to infection or inflammation. The normal value is 3,000 to 7,000/cmm (males) and 1,800 to 7,700/cmm (females). p. 889

Which is a symptom of severe thrombocytopenia?

Petechiae Clients with severe thrombocytopenia have petechiae, which are pinpoint hemorrhagic lesions, usually more prominent on the trunk or anterior aspects of the lower extremities. p. 893

A nurse is assisting a client into position prior to bone marrow aspiration. Which position will the nurse place the client prior to the procedure?

Prone Prior to the bone marrow aspiration, the nurse should place the client in either the prone position or lateral position with one leg flexed. The aspiration usually is performed on the anterior iliac crest. It would not be appropriate for the nurse to place the client in supine, knee-chest, or Trendelenburg positions. p. 895

A patient is undergoing platelet pheresis at the outpatient clinic. What does the nurse know is the most likely clinical disorder the patient is being treated for?

Essential thrombocythemia Platelet pheresis is used to remove platelets from the blood in patients with extreme thrombocytosis or essential thrombocythemia (temporary measure)or in a single-donor platelet transfusion. p. 896

Under normal conditions, the adult bone marrow produces approximately 70 billion neutrophils. What is the major function of neutrophils?

Phagocytosis The major function of neutrophils is phagocytosis. T lymphocytes are responsible for rejection of foreign tissue and destruction of tumor cells. Plasma cells produce antibodies call immunoglobulin. p. 887

The health care provider believes that the client has a deficiency in the leukocyte responsible for cell-mediated immunity. What should the nurse check the WBC count for?

T lymphocytes T lymphocytes are responsible for cell-mediated immunity, in which they recognize material as "foreign," acting as a surveillance system. p. 889

The nurse expects which assessment finding of the oral cavity when the client is diagnosed with pernicious anemia?

Smooth tongue On physical assessment, the nurse expects to observe a smooth tongue in the client diagnosed with pernicious anemia. Angular cheilosis (ulceration of the corners of the mouth) is seen with anemia. Ulcerations of the oral cavity indicate infection or possible leukemia. Enlarged gums can be indicative of leukemia. p. 893

A nurse cares for a client with megaloblastic anemia who had a total gastrectomy three years ago. What statement will the nurse include in the client's teaching regarding the condition?

"The condition is likely caused by a vitamin B12 deficiency." Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12 -intrinsic factor complex is absorbed in the distal ileum. Clients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and the absorption of vitamin B12 may be diminished. Megaloblastic anemia may be caused by a folate deficiency; however, the client's history of gastrectomy indicates the likely cause is a vitamin B12 deficiency. Megaloblastic anemia causes large erythrocytes (RBCs), not small or rigid. p. 888

The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level?

Decreased oxygen level. Hemoglobin carries oxygen; a decreased hemoglobin level results in decreased oxygen. An elevated temperature is a sign of infection and can result from decreased white blood cells. Arterial blood is more oxygen saturated and brighter red in color than venous blood. Increased bruising results from a decreased platelet level, not decreased hemoglobin. p. 887

The charge nurse should intervene when observing a new nurse perform which action after a client has suffered a possible hemolytic blood transfusion reaction?

Disposing of the blood container and tubing in biohazard waste. The blood container and tubing should be returned to the blood bank for repeat typing and culture, and the blood bank should be notified of the reaction. A urine sample is collected as soon as possible to detect hemoglobin in the urine. Documenting the client's reaction in the medical record is an appropriate action. p. 906

A patient will need a blood transfusion for the replacement of blood loss from the gastrointestinal tract. The patient states, "That stuff isn't safe!" What is the best response from the nurse?

"I understand your concern. The blood is carefully screened but is not completely risk free." Despite advances in donor screening and blood testing, certain diseases can still be transmitted by transfusion of blood components (Chart 32-4). p. 904

A nurse is teaching a client with a vitamin B12 deficiency about appropriate food choices to increase the amount of B12 ingested with each meal. The nurse knows the teaching is effective based on which statement by the client?

"I will eat a meat source such as chicken or pork with each meal." Vitamin B12 is found only in foods of animal origin. The other choices do not include meats. Dairy products contain large amounts of Calcium and vitamin D. Orange vegetables contain large amounts of vitamin A. p. 888

The nurse should provide further teaching about post bone-marrow biopsy procedures when the client makes which statement?

"I'll ask someone to drive me home when I awake from general anesthesia." A bone marrow biopsy is usually performed with local anesthesia, not general. Aspirin can increased the risk of bleeding and should be avoided post procedure. The client should expect to feel some aching in the hip area for 1-2 days. A sterile dressing is applied upon completion of the procedure and should remain in place until the healthcare provider tells the client it is safe to remove. p. 894

A preoperative client is discussing blood donation with the nurse. Which statement by the client indicates to the nurse the need for further teaching?

"My family will donate blood, because it's safer." Directed donations from friends and family members are not any safer than those provided by random donors. Withdrawal of 450 mL of blood usually takes about 15 minutes. Specimens from donated blood are tested to detect infections and to identify the specific blood type. Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high. p. 898

A client with a low red blood cell count is prescribed erythropoietin to be able to have autologous transfusion during planned joint replacement surgery. The nurse knows that which information will be important for the client to understand about this medication?

"The medication should be given by subcutaneous injection." Erythropoietin stimulates erythropoiesis and can be used to enable a client to donate several units of blood for future use or preoperative autologous donation. The medication can be administered IV or subcutaneously, although plasma levels are better sustained with the subcutaneous route. Serial complete blood counts must be performed to evaluate the response to the medication. The dose and frequency of administration are titrated to the hemoglobin level. Side effects are rare, but erythropoietin can cause or exacerbate hypertension. p. 887

Place the following procedural steps in order for transfusing a unit of packed red blood cells (PRBCs).

1. Start an intravenous line. 2. Obtain the unit of PRBCs from the blood bank. 3. Double check the labels with another nurse to ensure correct ABO group and Rh type. 4. Initiate the blood transfusion within 30 minutes of receipt. 5. Monitor closely for signs of a transfusion reaction. The nurse should first start an intravenous line, obtain the PRBCs, double check labels, start the transfusion, and then monitor for a reaction. p. 901

A client with a history of congestive heart failure has an order to receive 1 unit of packed red blood cells (RBCs). If the nurse hangs the blood at 12:00 pm, by what time must the infusion be completed?

4:00 pm When packed red blood cells (PRBCs) or whole blood is transfused, the blood should be administered within a 4-hour period because warm room temperatures promote bacterial growth. p. 901

A nurse is preparing a dose of furosemide for an older adult with heart failure. The health care provider orders furosemide 1 mg/kg to be given intravenously. The client weighs 50 kg. The concentration of the drug is 40 mg/4mL (10 mg/mL). How many milliliters would the nurse administer? Record your answer using a whole number.

5 1 mg/kg X 50 kg = 50 mg then divide by 10 mg/mL = 5 mL p. ---

A client with Hodgkin disease had a bone marrow biopsy yesterday and reports aching at the biopsy site, rated a 5 (on a 1-10 scale). After assessing the biopsy site, which nursing intervention is most appropriate?

Administer acetaminophen 500 mg po, as ordered After a marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing. Most clients have no discomfort after a bone marrow biopsy, but the site of a biopsy may ache for 1 or 2 days. Warm tub baths and a mild analgesic agent (e.g., acetaminophen) may be useful. Aspirin-containing analgesic agents should be avoided it the immediate post-procedure period because they can aggravate or potentiate bleeding. p. 894

The nurse is obtaining the health history of a client suspected of having a hematological condition. The nurse notes the client has a history of alcohol abuse. Which clinical presentation is related to alcohol consumption?

Anemia Individuals with a history of alcohol consumption may have anemia due to nutritional deficiencies. Myelodysplastic syndrome, neutropenia, and thrombocytopenia are not common findings in clients who consume or abuse alcohol. p. 893

The physician performs a bone marrow biopsy from the posterior iliac crest on a client with pancytopenia. What intervention should the nurse perform after the procedure?

Apply pressure over the site for 5-7 minutes Hazards of either bone marrow aspiration or biopsy include bleeding and infection. The risk of bleeding is somewhat increased if the client's platelet count is low or if the client has been taking a medication (e.g., aspirin) that alters platelet function. After the marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing. p. 894

Which of the following cells are capable of differentiating into plasma cells?

B lymphocytes B lymphocytes are capable of differentiating into plasma cells. Plasma cells, in turn, produce antibodies called immunoglobulins (Ig), which are protein molecules that destroy foreign material by several mechanisms. T lymphocytes, eosinophils, and neutrophils do not differentiate into plasma cells. p. 889

Which type of leukocyte contains histamine and is an important part of hypersensitivity reactions?

Basophils Basophils contain histamine and are an integral part of hypersensitivity reactions. B lymphocytes are responsible for humoral immunity. A plasma cell secretes immunoglobulins. The neutrophil functions in preventing or limiting bacterial infection via phagocytosis. p. 889

A client is experiencing symptoms of myelodysplastic syndrome (MDS). The nurse prepare the client for which type of test to aid in diagnosing this condition?

Bone marrow aspiration and biopsy The official diagnosis of MDS is based on the results of a bone marrow aspiration (to assess dysplasia) and biopsy (to assess characteristics of the affected cells). These tests help in determining prognosis, risk of leukemic transformation, and in some clients, the most effective therapy. Hematocrit, hemoglobin, and complete blood count are not used to definitively diagnose MDS. p. 894

A client with myelodysplastic syndromes (MDS) receives routine blood transfusions. Which treatment will the nurse expect to be prescribed to prevent the development of iron overload?

Chelation therapy Iron overload is a problem for clients with MDS, especially in those who routinely receive PRBC transfusions (transfusion dependent). Surplus iron is deposited in cells within the reticuloendothelial system, and later in parenchymal organs. To prevent or reverse the complications of iron overload, iron chelation therapy is commonly implemented. Romiplostim and eltrombopag are used to stimulate the proliferation and differentiation of megakaryocytes into platelets within the bone marrow. Epoetin alpha may be used to improve anemia and decrease the need for blood transfusions. p. 905

A nursing instructor in a BSN program is preparing for a lecture on disorders of the hematopoietic system. Included in the lecture are conditions caused by reduced levels or absence of blood-clotting proteins. Which of the following is the instructor most likely referring to?

Coagulopathy The term coagulopathy refers to conditions in which a component that is necessary to control bleeding is missing or inadequate. p. 893

The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise?

Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Isometric exercise induce contraction of skeletal muscle so that it compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Isometric exercises do not have an aerobic effect and should not increase the heart rate; although, it may increase blood pressure. Isometric exercise does not decrease the workload of the heart. Arterial flow moves blood flow away from the heart after being oxygenated. p. 896

A patient with chronic kidney disease is being examined by the nurse practitioner for anemia. The nurse has reviewed the laboratory data for hemoglobin and RBC count. What other test results would the nurse anticipate observing?

Decreased level of erythropoietin Differentiation of the primitive myeloid stem cell into an erythroblast is stimulated by erythropoietin, a hormone produced primarily by the kidney. If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (i.e., anemia), or with people living at high altitudes with lower atmospheric oxygen concentrations, erythropoietin levels increase. The increased erythropoietin then stimulates the marrow to increase production of erythrocytes. The entire process of erythropoiesis typically takes 5 days (Cook, Ineck, & Lyons, 2011). For normal erythrocyte production, the bone marrow also requires iron, vitamin B12, folate, pyridoxine (vitamin B6), protein, and other factors. A deficiency of these factors during erythropoiesis can result in decreased red cell production and anemia. p. 887

When conducting a health assessment on a client suspected for having a hematological disorder, the nurse should collect which data? Select all that apply.

Dietary intake Medication use Ethnicity Herbal supplements NOT: Hair color Dietary intake, ethnicity, use of herbal supplements, and medication use are factors for which the nurse should assess. Hair color is not considered a factor in determining causes of hematological disorders. p. 891

A client donated two units of blood to be used for transfusion during spinal fusion surgery. The client received one unit of autologous blood during the procedure but the second unit is not needed during the procedure. The nurse knows which action will come after the procedure is completed?

Discard the additional unit. In autologous donation, the client's own blood is collected for a future transfusion, particularly for an elective surgery where the potential for transfusion is high, such as an orthopedic procedure. If the blood is not used, it is discarded. The blood is not used for its components. The client will not be given the unit of blood unless it is required. The additional unit will not be released to the general population for use. p. 898

A client receiving a unit of packed red blood cells (PRBCs) has been prescribed morphine 1 mg intravenously now for pain. What is the best method for the nurse to administer the morphine?

Disconnect the blood tubing, flush with normal saline, and administer morphine. Never add medications to blood or blood products. The transfusion must be temporarily stopped in order to administer the morphine. p. 901

During a blood transfusion with packed red blood cells (RBCs), a client reports chills, low back pain, and nausea. What priority action should the nurse take?

Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing The following steps are taken to determine the type and severity of the reaction: Stop the transfusion. Maintain the IV line with normal saline solution through new IV tubing, administered at a slow rate. Assess the client carefully. Notify the physician. Continue to monitor the client's vital signs and respiratory, cardiovascular, and renal status. Notify the blood bank that a suspected transfusion reaction has occurred. Send the blood container and tubing to the blood bank for repeat typing and culture. p. 906

A client receiving a blood transfusion reports shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the health care provider?

Ensure there is an oxygen delivery device at the bedside. The client is exhibiting signs of circulatory overload. After stopping the transfusion and notifying the healthcare provider, the nurse should place the client in a more upright position with the legs dependent to decrease workload on the heart. The IV line is kept patent in case emergency medications are needed. Oxygen and morphine may be needed to treat severe dyspnea. Administering an anti-anxiety agent is not a priority action over ensuring oxygen is available. p. 901

A client with chronic kidney disease has chronic anemia. What pharmacologic alternative to blood transfusion may be used for this client?

Erythropoietin Erythropoietin (epoetin alfa [Epogen, Procrit]) is an effective alternative treatment for clients with chronic anemia secondary to diminished levels of erythropoietin, as in chronic renal disease. This medication stimulates erythropoiesis. p. 906

A client wants to donate blood before his or her abdominal surgery next week. What should be the nurse's first action?

Explain the time frame needed for autologous donation. Preoperative autologous donations are ideally collected 4 to 6 weeks before surgery. The nurse should first explain that time frame to this client. Surgery is scheduled in one week which means that autologous blood donation may not be an option for this client. A list of donation centers can be provided to the client; and even though iron is recommended and 2 units of blood may be suggested, the first action is to tell the client about the needed time frame for donation. p. 898

The nurse cares for a client with a coagulation factor deficiency who is actively bleeding. Which blood component replacement does the nurse anticipate administering?

FFP Fresh frozen plasma has all the coagulation factors in it and is the blood component replacement therapy that will be used to replace blood from a client who is actively bleeding with a coagulation factor deficiency. p. 902

The nurse assesses a client experiencing frequent nosebleeds. Which findings indicate to the nurse that additional assessment would be needed for thrombocytopenia? Select all that apply.

Headache Ecchymoses on the skin Conjunctival hemorrhage Petechiae over lower extremities NOT: Cloudy urine A history of nosebleeds (epistaxis) is a potential indication of thrombocytopenia. Additional findings associated with thrombocytopenia include a headache associated with central nervous system involvement. Ecchymoses, conjunctival hemorrhage, and petechiae over the lower extremities suggest thrombocytopenia is affecting the skin and associated structures of the head and neck. Cloudy urine would be associated with a urinary tract infection. Hematuria would be the finding if thrombocytopenia is affecting the genitourinary system. p. 893

Which term refers to the percentage of blood volume that consists of erythrocytes?

Hematocrit Hematocrit is the percentage of blood volume consisting of erythrocytes. Differentiation is development of functions and characteristics that differ from those of the parent stem cell. ESR is a laboratory test that measures the rate of settling of RBCs; an elevated rate is indicative of inflammation. Hemoglobin is the iron-containing protein of RBCs. p. 892

Which term describes the percentage of blood volume that consists of erythrocytes?

Hematocrit Hematocrit is the percentage of blood volume consisting of erythrocytes. Differentiation is the development of functions and characteristics that differ from those of the parent stem cell. ESR is a laboratory test that measures the rate of settling of red blood cells (RBCs); an elevated rate is indicative of inflammation. Hemoglobin is the iron-containing protein of RBCs. p. 892

A nurse is performing an initial assessment and notes the client's skin is a gray-tan color, especially on the scars of the client's arms. Which hematological condition does the nurse suspect?

Hemochromatosis Hemochromatosis is an autosomal recessive disease of excessive iron absorption. This results in bronze or gray-tan skin, especially over scars. The other answer choices are hematological conditions; however, these do not cause the skin to turn a gray-tan color. p. 893

A client's electronic health record states that the client receives regular transfusions of factor IX. The nurse would be justified in suspecting that this client has what diagnosis?

Hemophilia Administration of clotting factors is used to treat diseases where these factors are absent or insufficient; hemophilia is among the most common of these diseases. Factor IX is not used in the treatment of leukemia, lymphoma, or anemia. p. 896

A nurse is caring for a patient who has had a bone marrow aspiration with biopsy. What complication should the nurse be aware of and monitor the patient for?

Hemorrhage Hazards of either bone marrow aspiration or biopsy include bleeding and infection. The risk of bleeding is somewhat increased if the patient's platelet count is low or if the patient has been taking a medication (e.g., aspirin) that alters platelet function. p. 894

A client is being treated for chronic myeloid leukemia (CML). Which medication will the nurse expect to be prescribed for this client?

Imatinib mesylate The goal of treatment for CML is to control the disease, either by obtaining remission or by keeping the client in the chronic phase for as long as possible. The use of tyrosine kinase inhibitors, such as imatinib mesylate (TKIs), has significantly improved treatment and long-term survival for patients with CML. The TKI imatinib mesylate is considered to be standard of care for clients with CML. TKIs work by blocking the signals within the leukemic cells that express the BCR-ABL protein. This inhibition prevents a series of chemical reactions that cause the cells to grow and divide, thus inducing complete remission at the cellular level. Antacids such as calcium carbonate, corticosteroids such as prednisone, and antiseizure such as dilantin medications decrease the effects of TKIs and are not used control CML. p. ---

A nurse cares for a client with myelodysplastic syndrome who requires frequent PRBC transfusions. What blood component does the nurse recognize as being most harmful if accumulated in the tissues due to chronic blood transfusions?

Iron Iron overload is a complication unique to people who have had long-term PRBC transfusion. Over time, the excess iron deposits in body tissues can cause organ damage, particularly in the liver, heart, testes, and pancreas. p. 905

The nurse is caring for a client who has a unit of whole blood removed every 6 weeks as treatment for polycythemia vera. Which laboratory test will the nurse monitor to determine if the procedure is adversely affecting the client?

Iron Therapeutic phlebotomy is the removal of a certain amount of blood under controlled conditions. A client with an elevated hematocrit from polycythemia vera can usually be managed by periodically removing 1 unit (about 500 mL) of whole blood. Over time, this process can produce iron deficiency, Therapeutic phlebotomy does not affect the calcium or potassium levels or the white blood cell count. p. 896

A patient who has long-term packed RBC (PRBC) transfusions has developed symptoms of iron toxicity that affect liver function. What immediate treatment should the nurse anticipate preparing the patient for that can help prevent organ damage?

Iron chelation therapy Iron overload is a complication unique to people who have had long-term PRBC transfusions. One unit of PRBCs contains 250 mg of iron. Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. Over time, the excess iron deposits in body tissues and can cause organ damage, particularly in the liver, heart, testes, and pancreas. Promptly initiating a program of iron chelation therapy can prevent end-organ damage from iron toxicity. p. 905

A client reports feeling faint after donating blood. What is the nurse's best action?

Keep client in recumbent position to rest. After blood donation, the donor should remain recumbent until he or she feels able to sit up. Donors who experience weakness or faintness should rest for a longer period. High-Fowler's position would not promote blood flow to the brain, and could cause the client to feel light-headed or faint. Ambulating a client who feels faint is not safe due to the high risk of falling. Trendelenburg position is not recommended after blood donation. p. 898

A client in acute renal failure has been prescribed 2 units of packed red blood cells (PRBCs). The nurse explains to the client that the blood transfusion is most likely needed for which reason?

Lack of erythropoietin The kidneys produce erythropoietin, a hormone that stimulates red blood cell production. A lack of this hormone is the most likely reason for blood transfusion due to the acute kidney failure. There is no indication for a nephrectomy in this question. A blood transfusion will not necessarily increase the effectiveness of dialysis. Transfusing a client with hypervolemia could lead to circulatory overload. p. 887

The nurse is preparing a patient for a bone marrow aspiration and biopsy from the site of the posterior superior iliac crest. What position will the nurse place the patient in?

Lateral position with one leg flexed Bone marrow aspiration procedure. The posterior superior iliac crest is the preferred site for bone marrow aspiration and biopsy because no vital organs or vessels are nearby. The patient is placed either in the lateral position with one leg flexed or in the prone position. p. 895

The nurse is providing health education to an older adult client who has low red blood cell levels. To promote red blood cell production, the nurse should encourage intake of what foods? Select all that apply.

Leafy green vegetables Lean meats Nuts and seeds NOT: Animal fats NOT: Organic foods A healthy diet that includes lean meats, nuts, seeds and green vegetables can promote red cell production. Animal fats are not known to promote red cell production. Organic foods are not necessarily more likely to promote red cell synthesis. p. 887

What food should the nurse recommend for a client diagnosed with vitamin B12 deficiency?

Lean meat Vitamin B12 is only found in foods of animal origin. Therefore, whole-grain bread, green vegetables, and citrus fruit do not contain this vitamin. p. 888

Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following?

Liver Albumin is produced by the liver. Albumin is not produced in the pancreas, kidney, or large intestine. p. 890

What does the nurse recognize as secondary sites of hematopoiesis that is unique to embryonic development? Select all that apply.

Liver Spleen NOT: Bone marrow NOT: Kidney NOT: Pancreas The spleen and liver may be involved in hematopoiesis during normal embryonic development. The bone marrow is the primary site of hematopoiesis and is not unique to this population. The kidney stimulates the hormone erythropoietin, which in turn stimulates the marrow to produce more erythrocytes; however, the kidney is not the site of hematopoiesis. The pancreas is not the site of hematopoiesis. p. 885

Which term refers to a form of white blood cell involved in immune response?

Lymphocyte Mature lymphocytes are the principal cells of the immune system, producing antibodies and identifying other cells and organisms as "foreign." B and T lymphocytes respond to exposure to antigens. Granulocytes include basophils, neutrophils, and eosinophils. A spherocyte is a red blood cell without central pallor, seen with hemolysis. A thrombocyte is a platelet. p. 885, 889

Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets?

Myeloid stem cell Myeloid stem cells are responsible not only for all nonlymphoid white blood cells (WBC) but also for the production of red blood cells and platelets. Lymphoid cells produce either T or B lymphocytes. A monocyte is large WBC that becomes a macrophage when is leaves the circulation and moves into body tissues, and not responsible for RBC production.. A neutrophil is a fully mature WBC capable of phagocytosis and not responsible for RBC production. p. 886

A client involved in a motor vehicle accident arrives at the emergency department unconscious and severely hypotensive. The nurse suspects the client has several fractures in the pelvis and legs. Which parenteral fluid is the best choice for the client's current condition?

Packed red blood cells (RBCs) In a trauma situation, the first blood product given is unmatched (O negative) packed RBCs. Fresh frozen plasma is commonly used to replace clotting factors. Normal saline or lactated Ringer's solution is used to increase volume and blood pressure; however, too much colloid will hemodilute the blood and doesn't improve oxygen-carrying capacity as well as packed RBCs do. p. 901

Which is the major function of neutrophils?

Phagocytosis Once a neutrophil is released from the marrow into the circulation, it stays there for only about 6 hours before it migrates into the body tissues to perform its function of phagocytosis (ingestion and digestion of bacteria and particles). Neutrophils die there within 1 to 2 days. T lymphocytes are responsible for rejection of foreign tissue and destruction of tumor cells. Plasma cells produce antibodies called immunoglobulins. p. 887

The client is diagnosed with polycythemia vera. The nurse prepares the client for which procedure?

Phlebotomy Polycythemia vera is a condition in which the blood contains a large amount of red blood cells, increasing the viscosity of the blood. Phlebotomy is a preferred treatment to rid the circulation of excess red blood cells. Apheresis is a process in which platelets and leukocytes are removed from the blood. Blood and platelet infusions can exacerbate this condition. p. 896

A nurse cares for several mothers and babies in the postpartum unit. Which mother does the nurse recognize as being most at risk for a febrile nonhemolytic reaction?

Rh-negative mother; Rh-positive child A mother who is Rh negative and gives birth to an Rh positive child is at greatest risk for a febrile nonhemolytic reaction because exposure to an Rh-positive fetus raises antibody levels in the Rh negative mother. An Rh-negative mother can carry an Rh-negative child without being at greatest risk for a febrile nonhemolytic reaction; however, these mothers are often treated prophylactically. An Rh-positive mother may carry either an Rh-positive or Rh-negative child without increased risk. p. 902

A nurse practitioner reviewed the blood work of a male client suspected of having microcytic anemia. The nurse suspected occult bleeding. Which laboratory result would indicate an initial stage of iron deficiency?

Serum ferritin: 15 ng/mL Microcytic anemia is characterized by small RBCs due to insufficient hemoglobin. Serum ferritin levels correlate to iron deficiency and decrease as an initial response to anemia before hemoglobin and serum iron levels drop. p. 888

Place the following steps in order when determining the type and severity of a transfusion reaction. Use all options.

Stop the transfusion. Assess the client. Notify the health care provider. Notify the blood bank. Send the tubing and container to the blood bank. It is important for the nurse to take the proper steps when determining the type and severity of a transfusion reaction. The priority action is to stop the infusion and then assess the client. Next, the health care provider will be notified, followed by the blood bank. Finally, the nurse should send the tubing and container to the blood bank for analysis. p. 906

Which type of lymphocyte is responsible for cellular immunity?

T lymphocyte T lymphocytes are responsible for delayed allergic reactions, rejection of foreign tissue (e.g., transplanted organs), and destruction of tumor cells. This process is known as cellular immunity. B lymphocytes are responsible for humoral immunity. A plasma cell secretes immunoglobulin. A basophil contains histamine and is an integral part of hypersensitivity reactions. p. 887

A nurse, caring for a client with human immunodeficiency virus (HIV), reviews the client's differential WBC count. What type of WBC will the nurse check the level of?

T lymphocytes Lymphocytes (T cells, B cells, and natural killer cells) are WBCs that are the major components of the body's immune response. T cells are primarily responsible for cell-mediated immunity, whereas B cells are involved in antibody production. p. 889

A nurse is caring for a client with a diagnosis of lymphocytopenia. Which assessment finding will the nurse consider most concerning when caring for this client?

Temperature of 37.7 degrees Celsius Lymphocytopenia is a decrease in the number of lymphocytes. Lymphocytes help to fight foreign invaders, such as infectious organisms. A temperature of 37.7 degree Celsius is a Fahrenheit temperature of 99.9. A low-grade fewer may be indicative of an infection. The other answer choices do not suggest infection and are not the priority concern. p. ---

The nurse is administering a blood transfusion to a client over 4 hours. After 2 hours, the client reports chills and has a fever of 101°F, an increase from a previous temperature of 99.2°F. What does the nurse recognize is occurring with this client?

The client is having a febrile nonhemolytic reaction. The signs and symptoms of a febrile nonhemolytic transfusion reaction are chills (minimal to severe) followed by fever (more than 1°C elevation). The fever typically begins within 2 hours after the transfusion is begun. Although the reaction is not life threatening, the fever, and particularly the chills and muscle stiffness, can be frightening to the client. p. 902

The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells?

The kidneys sense low oxygen levels in the blood and produce erythropoietin, stimulating the bone marrow to produce more red blood cells. If normally functioning kidneys detect low levels of blood oxygen, as occurs when fewer red cells are available to bind oxygen (as with anemia), they produce more of the hormone erythropoietin (EPO). As EPO levels increase, the bone marrow responds by producing more erythrocytes (red blood cells). EPO is not made by the bone marrow. Hemoglobin, an iron-rich protein that allows erythrocytes to transport oxygen, is synthesized in the erythrocytes as they mature. p. 887

The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells?

The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells. If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (as with anemia), erythropoietin levels increase, stimulating the marrow to produce more erythrocytes (red blood cells). p. 887

The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells?

The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells. If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (as with anemia), erythropoietin levels increase, stimulating the marrow to produce more erythrocytes (red blood cells). p. 887

A nursing instructor is reviewing the role and function of stem cells in the bone marrow with a group of nursing students. After providing the explanation, the instructor asks the students to use their knowledge of anatomy and physiology to determine an alternate way in which adults with diseases that destroy marrow can resume production of blood cells. Which explanation by the students is correct?

The liver and spleen can resume production of blood cells through extramedullary hematopoiesis. In adults with disease that destroy marrow or cause fibrosis or scarring, the liver and spleen can also resume production of blood cells through a process known as extramedullary hematopoiesis. p. 885

A nurse working in hematology reviews the characteristics of stem cells and their role in disease. Which statements does the nurse understand is true regarding stem cells? Select all that apply.

There is a continuous supply throughout the life cycle. Lymphoid stem cells produce lymphocytes. Myeloid stem cells produce erythrocytes. They have the ability to self-replicate. NOT: There is a limited supply throughout the life cycle. The primitive cells of the bone marrow are called stem cells. Stem cells have the ability to self-replicate, ensuring a continuous supply throughout the life cycle. Stem cells have the ability to differentiate—becoming either lymphoid stem cells (which produce lymphocytes) or myeloid stem cells (which produce erythrocytes). p. 885

One hour after the completion of a fresh frozen plasma transfusion, a client reports shortness of breath and is very anxious. The client's vital signs are BP 98/60, HR 110, temperature 99.4°F, and SaO2 88%. Auscultation of the lungs reveals posterior coarse crackles to the mid and lower lobes bilaterally. Based on the symptoms, the nurse suspects the client is experiencing which problem?

Transfusion-related acute lung injury Transfusion-related acute lung injury (TRALI) is a potentially fatal, idiosyncratic reaction that is defined as the development of acute lung injury within 6 hours after a blood transfusion. It is more likely to occur when plasma and platelets are transfused. Onset is abrupt (usually within 6 hours of transfusion, often within 2 hours). Signs and symptoms include acute shortness of breath, hypoxia (arterial oxygen saturation [SaO2] less than 90%; pressure of arterial oxygen [PaO2] to fraction of inspired oxygen [FIO2] ratio less than 300), hypotension, fever, and eventual pulmonary edema. p. 904

While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client?

Use an electric razor when assisting client with shaving. Petechiae are associated with severe thrombocytopenia, placing the client at risk for bleeding. The nurse should use an electric razor when assisting the client with shaving. Elevating the head of the bed and applying supplemental oxygen would be appropriate for a client with decreased oxygenation. Wearing a mask when entering the client's room would be appropriate for a client with neutropenia, not thrombocytopenia. p. 893

The physician orders a transfusion with packed red blood cells (RBCs) for a client hospitalized with severe iron deficiency anemia. When blood is administered, what is the most important action the nurse can take to prevent a transfusion reaction?

Verify the client's identity according to hospital policy Acute hemolytic transfusion reactions are preventable. Improper identification is responsible for the majority of hemolytic transfusion reactions. Meticulous attention to detail in labeling blood samples and blood components and accurately identifying the recipient cannot be overemphasized. It is the nurse's responsibility to ensure that the correct blood component is transfused to the correct client. The nurse must assess the client during the initial start of the transfusion and frequently, if the nurses delays the assessment time for 30 minutes the client may have begun to experience acute hemolytic transfusion reaction, this puts the client's safety at risk. p. 902

A client comes into the emergency department reporting an enlarged tongue. The tongue appears smooth and beefy red in color. The nurse also observes a 5-cm incision on the upper left quadrant of the abdomen. When questioned, the client states, "I had a partial gastrostomy 2 years ago." Based on this information, the nurse attributes these symptoms to which problem?

Vitamin B12 deficiency Because vitamin B12 is found only in foods of animal origin, strict vegetarians may ingest little vitamin B12. Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12-intrinsic factor complex is absorbed in the distal ileum. Clients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and therefore the absorption of vitamin B12 may be diminished. The effects of either decreased absorption or decreased intake of vitamin B12 are not apparent for 2-4 years. This results in megaloblastic anemia. Some symptoms are a smooth, beefy red, enlarged tongue and cranial nerve deficiencies. p. 888

A nurse is reviewing a client's morning laboratory results and notes a left shift in the band cells. Based on this result, the nurse can interpret that the client

may be developing an infection. Less mature granulocytes have a single-lobed, elongated nucleus and are called band cells. Ordinarily, band cells account for only a small percentage of circulating granulocytes, although their percentage can increase greatly under conditions in which neutrophil production increases, such as infection. An increased number of band cells is sometimes called a left shift or shift to the left. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of white blood cells in circulation. Thrombocytopenia refers to a lower-than-normal platelet count. p. 889

A nurse is reviewing a client's morning laboratory results and notes a left shift in the band cells. Based on this result, the nurse can interpret that the client

may be developing an infection. Less mature granulocytes have a single-lobed, elongated nucleus and are called band cells. Ordinarily, band cells account for only a small percentage of circulating granulocytes, although their percentage can increase greatly under conditions in which neutrophil production increases, such as infection. An increased number of band cells is sometimes called a left shift or shift to the left. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of white blood cells in circulation. Thrombocytopenia refers to a lower-than-normal platelet count. p. 889