Ch. 20 : Nursing Management: Patients w/ Hematologic Disorders

A client's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC?

"DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs." The inflammatory response initiates the process of inflammation and coagulation. The natural anticoagulant pathways within the body are simultaneously impaired, and the fibrinolytic system is suppressed, allowing a massive amount of tiny clots forms in the microcirculation. As the platelets and clotting factors form microthrombi, coagulation fails. Thus, the paradoxical result of excessive clotting is bleeding. Decline in organ function is usually a result of excessive clot formation (with resultant ischemia to all or part of the organ).

A woman's routine complete blood count (CBC) revealed a highly elevated platelet level, and subsequent diagnostic testing has resulted in a diagnosis of primary thrombocythemia. The nurse has begun the relevant health education with the patient. What should the nurse teach this woman about her health problem?

"Primary thrombocythemia creates potential problems at both ends of the clotting spectrum: inappropriate clotting or inappropriate bleeding." Explanation: Primary thrombocythemia creates risks for significant thrombotic or hemorrhagic complications. Clotting factors and transfusions are not relevant treatments, and a high-iron diet is not necessary.

Parents arrive to the clinic with their young child and inform the nurse the child has just been diagnosed with sickle cell disease. The parents ask the nurse how this could have happened and which one of them is the carrier. What is the best response by the nurse?

"The child must inherit two defective genes, one from each parent." Sickle cell disease is a hereditary disorder. To manifest this disorder, a person must inherit two defective genes, one from each parent, in which case all the hemoglobin is inherently abnormal. If the person inherits only one gene, the person carries the sickle cell trait. The hemoglobin of those who have sickle cell trait is about 40% affected. The other distractors are incorrect due to these factors.

A client presents with peripheral neuropathy and hypoesthesia of the feet. What is the best nursing intervention?

Assess for signs of injury. A client with hypoesthesia of the feet will have decreased sensation and numbness. The nurse should assess for signs of injury. If the client is injured, he or she will not be able to feel it; this could lead to the development of infection. Ambulation will not help the client, and elevating the legs may make the problem worse, as blood flow to the feet would be decreased. Keeping the feet cold will also decrease blood flow.

A client in end-stage renal disease is prescribed epoetin alfa and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, what is the priority action taken by the nurse?

Assesses the hemoglobin level Erythropoietin (epoetin alfa [Epogen]) with oral iron supplements can raise hematocrit levels in the client with end-stage renal disease. The nurse should check the hemoglobin prior to administration of erythropoietin, because too high a hemoglobin level can put the client at risk for heart failure, myocardial infarction, and cerebrovascular accident. Erythropoietin may be administered during dialysis treatments. The BUN will be elevated in the client with end-stage renal disease.

The nurse is caring for a client with type 2 diabetes who take metformin to manage glucose levels. The nurse recognizes the client may be most at risk for which vitamin deficiency?

B12 The medication metformin (Glucophage) increases the client's risk for developing B12 deficiency because the medication inhibits the absorption of B12.

When teaching a client with iron deficiency anemia about appropriate food choices, the nurse encourages the client to increase the dietary intake of which foods?

Beans, dried fruits, and leafy, green vegetables Food sources high in iron include organ meats (e.g., beef or calf liver, chicken liver), other meats, beans (e.g., black, pinto, and garbanzo), leafy and green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron.

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 Explanation: 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.

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. Explanation: Never add medications to blood or blood products. The transfusion must be temporarily stopped in order to administer the morphine.

You are caring for a 13-year-old diagnosed with sickle cell anemia. The client asks you what they can do to help prevent sickle cell crisis. What would be an appropriate answer to this client?

Drink at least 8 glasses of water every day. During the physical examination, observe the client's appearance, looking for evidence of dehydration, which may have triggered a sickle cell crisis. Clients are taught moderation, not avoidance of activities. Most clients with sickle cell disease are not on oxygen therapy 24/7.

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. Explanation: 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.

When assessing a female client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential?

Health history, such as bleeding, fatigue, or fainting When assessing a client with a disorder of the hematopoietic or the lymphatic system, it is essential to assess the client's health history. An assessment of drug history is essential because some antibiotics and cancer drugs contribute to hematopoietic dysfunction. Aspirin and anticoagulants may contribute to bleeding and interfere with clot formation. Because industrial materials, environmental toxins, and household products may affect blood-forming organs, the nurse needs to explore exposure to these agents. Age, gender, menstrual history, or lifestyle assessments, such as exercise routines and habits, do not directly affect the hematopoietic or lymphatic system.

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.

During the review of morning laboratory values for a client reporting severe fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron deficiency anemia based on which finding?

Low ferritin level concentration Explanation: The most consistent indicator of iron deficiency anemia is a low ferritin level, which reflects low iron stores. As the anemia progresses, the MCV, which measures the size of the erythrocytes, also decreases. Hematocrit and RBC levels are also low in relation to the hemoglobin concentration.

A patient, newly diagnosed with thrombocytopenia, is admitted to the medical unit. After the admission assessment the patient asks the nurse to explain the disease. What should the nurse explain to the patient about this condition?

There could be decreased production of platelets Thrombocytopenia can result from a decreased platelet production, increased platelet destruction, or increased consumption of platelets. Increased production of platelets is associated with thrombocythemia. Decreased white blood cell production is associated with leukopenia.

A client with sickle cell anemia has a

low hematocrit. A client with sickle cell anemia has a low hematocrit and sickled cells on the smear. A client with sickle cell trait usually has a normal hemoglobin level, a normal hematocrit, and a normal blood smear.

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?

"I will receive parenteral vitamin B12 therapy for the rest of my life." Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life.

Which patient assessed by the nurse is most likely to develop myelodysplastic syndrome (MDS)?

A 72-year-old patient with a history of cancer Explanation: Primary MDS tends to be a disease of people older than 70 years. Because the initial findings are so subtle, the disease may not be diagnosed until later in the illness trajectory, if at all. Thus, the actual incidence of MDS is not known.

The nurse suspects that a client has multiple myeloma based on the client's major presenting symptom and the analysis of laboratory results. What classic symptom for multiple myeloma does the nurse assess for?

Bone pain in the back of the ribs Although patients can have asymptomatic bone involvement, the most common presenting symptom of multiple myeloma is bone pain, usually in the back or ribs. Unlike arthritic pain, the bone pain associated with myeloma increases with movement and decreases with rest; clients may report that they have less pain on awakening but the pain intensity increases during the day.

A patient with end-stage kidney disease (ESKD) has developed anemia. What laboratory finding does the nurse understand to be significant in this stage of anemia?

Creatinine level of 6 mg/100 mL The degree of anemia in patients with end-stage renal disease varies greatly; however, in general, patients do not become significantly anemic until the serum creatinine level exceeds 3 mg/100 mL.

A client who is being treated for AML has bruises on both legs. What is the nurse's most appropriate action?

Evaluate the client's platelet count. Explanation: Complications of AML include bleeding. The risk of bleeding correlates with the level and duration of platelet deficiency. Major hemorrhages may develop when the platelet count drops to less than 10,000/mm3. The bleeding is usually unrelated to falling. Keeping the client on bed rest will not prevent bleeding when the client has a low platelet count. Assessment for other areas of bleeding is also a priority intervention.

When assessing a client with anemia, which assessment is essential?

Health history, including menstrual history in women When assessing a client with anemia, it is essential to assess the client's health history. Women should be questioned about their menstrual periods (e.g., excessive menstrual flow, other vaginal bleeding) and the use of iron supplements during pregnancy.

A patient with AML is having aggressive chemotherapy to attempt to achieve remission. The patient is aware that hospitalization will be necessary for several weeks. What type of therapy will the nurse explain that the patient will receive?

Induction therapy Despite advances in understanding of the biology of AML, substantive advances in treatment response rates and survival rates have not occurred for decades, with the exception of advances made in treating APL (see later discussion). Even for patients with subtypes that have not benefited from advances in treatment, cure is still possible. The overall objective of treatment is to achieve complete remission, in which there is no evidence of residual leukemia in the bone marrow. Attempts are made to achieve remission by the aggressive administration of chemotherapy, called induction therapy, which usually requires hospitalization for several weeks.

Which medication is the antidote to warfarin?

Vitamin K The antidote for warfarin is vitamin K. Protamine sulfate is the antidote for heparin. Aspirin and clopidogrel are both antiplatelet medications.

A teenaged client with hemophilia sustains a leg laceration after falling off a skateboard and is brought to the emergency department. The laceration is bleeding profusely even with direct pressure to the site. What does the nurse anticipate will be prescribed for administration to control bleeding?

Fresh frozen plasma Explanation: Treatment includes transfusion of fresh blood, frozen plasma, factor VIII concentrate, and anti-inhibitor coagulant complex for hemophilia A, factor IX concentrate for hemophilia B, factor XI for hemophilia C, and the application of thrombin or fibrin to the bleeding area. Other measures used to help control bleeding are the administration of fresh frozen plasma, aminocaproic acid that helps to hold a clot in place once it has formed, direct pressure over the bleeding site, and cold compresses or ice packs. Hetastarch, lactated Ringer's, or albumin will not control the bleeding related to hemophilia.

A client is scheduled for surgery to remove an abdominal mass. The nurse knows that which reason hemodilution would be contraindicated as a method to provide blood to the client during the surgery?

History of renal disease Hemodilution is the removal of 1 to 2 units of blood after induction of anesthesia and replaced with a colloid or crystalloid solution. The blood is then reinfused after the surgery. The purpose of this approach is to reduce the amount of erythrocytes lost during the surgery because the intravenous fluids dilute the concentration of red blood cells and lowers the hematocrit. Hemodilution has been linked to tissue ischemia in the kidneys and would be contraindicated in the client with a history of renal disease. Hemodilution would not be contraindicated for a previous thyroidectomy, treatment for osteoarthritis, or medication used to treat seasonal allergies.

The nurse is assessing a client with chronic lymphocytic leukemia. Which assessment findings indicate to the nurse that the client is experiencing B symptoms of the condition? Select all that apply.

Intermittent fever Drenching night sweats Unintentional weight loss of 10% Chronic lymphocytic leukemia (CLL) is a common malignancy of older adults, and the most prevalent type of adult leukemia in the Western world. Lymphocytosis is always present. Clients with CLL can develop B symptoms which indicates a worsening prognosis to include intermittent fevers, drenching night sweats, and an unintentional weight loss of 10% over the last 6 months. Epistaxis and ecchymosis are not symptoms of CLL.

The nurse is caring for a patient with a diagnosis of hypoproliferative anemia. When planning this patient's care, the nurse should be aware that this type of anemia is due to what?

Lack of production of red blood cells (RBCs) Hypoproliferative anemia is usually a result of inadequate numbers of RBCs being produced by the bone marrow. Loss of RBCs is usually a result of blood loss. Hemolytic anemia can be a result of injury to the RBCs in circulation, possibly due to heart valve hemolysis. Abnormality of RBCs can occur in sickle cell anemia.

A nursing instructor is evaluating a student caring for a neutropenic client. The instructor concludes that the nursing student demonstrates accurate knowledge of neutropenia based on which intervention?

Monitoring the client's temperature and reviewing the client's complete blood count (CBC) with differential Clients with neutropenia often do not exhibit classic signs of infection. Fever is the most common indicator of infection, yet it is not always present. No definite symptoms of neutropenia appear until the client develops an infection. A routine CBC with differential can reveal neutropenia before the onset of infection.

A client with a diagnosis of pernicious anemia comes to the clinic reporting of numbness and tingling in his arms and legs. What do these symptoms indicate?

Neurologic involvement In clients with pernicious anemia, numbness and tingling in the arms and legs and ataxia are the most common signs of neurologic involvement. Some affected clients lose vibratory and position senses. Jaundice, irritability, confusion, and depression are present when the disease is severe. Insufficient intake of dietary nutrients is not indicated by these symptoms

A client with a diagnosis of pernicious anemia comes to the clinic reporting of numbness and tingling in his arms and legs. What do these symptoms indicate?

Neurologic involvement Explanation: In clients with pernicious anemia, numbness and tingling in the arms and legs and ataxia are the most common signs of neurologic involvement. Some affected clients lose vibratory and position senses. Jaundice, irritability, confusion, and depression are present when the disease is severe. Insufficient intake of dietary nutrients is not indicated by these symptoms

A client with acute myeloid leukemia has a fever. What pathophysiological process does the nurse recognize is the cause of the client's fever?

Neutropenia Explanation: Fever and infection result from a decrease in neutrophils (neutropenia). Decreased red blood cells (anemia) cause weakness, fatigue, dyspnea on exertion, and pallor in AML. Pancytopenia, an overall decrease in all blood components, is not cause of fever in clients with AML. Decreased platelet count (thrombocytopenia) causes petechiae and bruising in AML.

The nurse provides care for an older adult client, diagnosed with anemia, who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine the cause of the client's blood loss, which is the priority nursing action?

Observe the client's stools for blood. If an older adult is anemic, blood loss from the gastrointestinal (GI) or genitourinary (GU) tracts is suspected. Observing the stool for blood will determine if the source of the client's bleeding is in the GI tract. Iron-deficiency anemia is unusual in older adults because the body does not eliminate excessive iron, thus increasing total body iron stores and necessitating maintenance of hydration. If evaluation of the GI and GU tracts does not reveal a source of bleeding, evaluating the client's diet may be appropriate; however, this is not the priority nursing action. Monitoring the client's body temperature and BP will assist the nurse in determining the source of the client's blood loss, but these are not priority nursing actions.

A patient receiving plasma develops transfusion-related acute lung injury (TRALI) 4 hours after the transfusion. What type of aggressive therapy does the nurse anticipate the patient will receive to prevent death from the injury? (Select all that apply.)

Oxygen Fluid support Intubation and mechanical ventilation Transfusion-related acute lung injury (TRALI) is a potentially fatal, idiosyncratic reaction that is defined as the development of acute lung injury occurring within 6 hours after a blood transfusion. Aggressive supportive therapy (e.g., oxygen, intubation, fluid support) may prevent death.

The hospitalized client is experiencing gastrointestinal bleeding with a platelets at 9,000/mm³. The client is receiving prednisone and azathioprine. What action will the nurse take?

Perform a neurologic assessment with vital signs. With platelets less than 10,000/mm³ there is a risk for spontaneous bleeding, including within the cranial vault. The nurse performs a neurologic examination to assess for this possibility. Though the client is receiving immunosuppressants, it is not necessary to use contact precautions with this client. Contact precautions are used with clients who have known or suspected transmittable illnesses. Diphenoxylate and atropine can cause constipation and inhibit accurate assessment of the client's gastrointestinal bleeding. If the client strains when having a bowel movement, the client could bleed even more. The client is not to floss vigorously; doing so can cause bleeding.

The nurse is working at a blood donation clinic. What teaching should the nurse provide to the donor immediately after blood donation?

Remain for observation after eating and drinking. After blood donation, the donor receives food and fluids and is asked to remain for observation. After the needle is removed, donors are asked to hold the involved arm straight up, and firm pressure is applied with sterile gauze for 2 to 3 minutes. A firm bandage is then applied. The donor remains recumbent until he or she feels able to sit up, usually within a few minutes.

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.

A client who is diagnosed with hemophilia is admitted after sustaining an injury while playing outdoors with friends. Initially, the client presented with severe bleeding but has since stabilized. Which intervention(s) should the nurse include in the client's updated plan of care? Select all that apply.

Support painful joints on pillows. Encourage the use a soft toothbrush for oral care. Educate to rinse the mouth with warm water between and after meals. Eliminate aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). The client who is diagnosed with hemophilia requires interventions that reduce pain and discomfort in addition to preventing further bleeding episodes; therefore, the interventions that are included in the updated plan of care by the nurse include supporting painful joints on pillows, encouraging the use of a soft toothbrush for oral care, educating the client to rinse the mouth with warm water between and after meals, and eliminating the use of NSAIDs and aspirin because these medications can increase bleeding tendencies. The nurse takes the client's temperature over the temporal artery or tympanically to avoid oral or rectal injuries; additionally, the nurse checks the urine and stools for signs of bleeding.

The nurse is assessing several clients. Which client does the nurse determine is most likely to have Hodgkin lymphoma?

The client with enlarged lymph nodes in the neck. Lymph node enlargement in Hodgkin lymphoma is not painful. The client with enlarged lymph nodes in the neck is most likely to have Hodgkin lymphoma if the enlarged nodes are painless. Sore throat is not a sign for this disorder.

A client is treated for anemia. What is the nurse's best understanding about the correlation between anemia and the client's iron stores?

There is a strong correlation between iron stores and hemoglobin levels. A strong correlation exists between laboratory values that measure iron stores and hemoglobin levels. After iron stores are depleted (as reflected by low serum ferritin levels), the hemoglobin level falls.

A nurse is doing a physical examination of a child with sickle cell anemia. When the child asks why the nurse auscultates the lungs and heart, what would be best the response by the nurse?

To detect the abnormal sounds suggestive of acute chest syndrome and heart failure Explanation: The nurse auscultates the lungs and heart to detect abnormal sounds that indicate pneumonia, acute chest syndrome, and heart failure. The nurse assesses vital signs to detect evidence of infection, such as fever and tachycardia. During the physical examination, the nurse observes the client's appearance, looking for evidence of dehydration, which may have triggered a sickle cell crisis. The nurse assesses mental status, verbal ability, and motor strength to detect stroke-related signs and symptoms.

The nurse in the oncology clinic is caring for a 42-year-old female client receiving chemotherapy with fludarabine for acute myeloid leukemia who has developed petechiae, epistaxis, and ecchymosis. The nurse anticipates that the client has developed ___________ and that the laboratory results will reveal _________.

hemorrhage; thrombocytopenia This client has manifestations of hemorrhage, including petechiae (pinpoint bleeding in the skin), epistaxis (nosebleeds), and ecchymosis (bruises) due to a low platelet count (thrombocytopenia) secondary to chemotherapy. Chemotherapy with fludarabine may cause bone marrow suppression with neutropenia (low neutrophil count) and thrombocytopenia (low platelet count). When the platelet count is low, the client is at risk for hemorrhage as evidenced by petechiae, epistaxis, and ecchymosis. Chemotherapy with fludarabine may cause bone marrow suppression, leading to thrombocytopenia (low platelet count) and hemorrhage. Although the client is at risk for infection, the assessment findings of petechiae, epistaxis, and ecchymoses are indicators of a low platelet count. The assessment findings do not support a diagnosis of deep vein thrombosis (DVT). Manifestations of DVT include calf pain, leg swelling, and warmth, and pain over the thrombosis. Hyperkalemia does n