Ch 29: Management of Patients with Nonmalignant Hematologic Disorders

d) Creatinine level of 6 mg/100 mL Pg. 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.

1. 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? a) Magnesium level of 2.5 mg/dL b) Calcium level of 9.4 mg/dL c) Potassium level of 5.2 mEq/L d) Creatinine level of 6 mg/100 mL

d) Protamine sulfate Pg. Protamine sulfate, in the appropriate dosage, acts quickly to reverse the effects of heparin. Vitamin K is the antidote to warfarin (Coumadin). Narcan is the drug used to reverse signs and symptoms of medication-induced narcosis. Ipecac is an emetic used to treat some poisonings.

20. Which of the following is considered an antidote to heparin? a) Ipecac b) Vitamin K c) Narcan d) Protamine sulfate

d) Sickle cell anemia Pg. 919 Glucose 6-phosphate dehydrogenase deficiency is an inherited abnormality resulting in hemolytic anemia. Autoimmune hemolytic anemia is an acquired anemia. Cold agglutinin disease is an acquired anemia. Hypersplenism results in an acquired hemolytic anemia.

9. Which type of hemolytic anemia is categorized as inherited disorder? a) Cold agglutinin disease b) Autoimmune hemolytic anemia c) Hypersplenism d) Sickle cell anemia

a) Closely monitor intake and output Pg. 940 The client with DIC is at a high risk of deficient fluid volume. The nurse can best gauge the effectiveness of care by closely monitoring the client's intake and output. Each of the other assessments is a necessary element of care, but none addresses fluid balance as directly as close monitoring of intake and output.

12. A client is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met? a) Closely monitor intake and output b) Assess skin integrity frequently c) Assess for edema d) Assess the client's level of consciousness frequently

b) Gradually taper the dose and frequency of medication Pg. 932 For a patient with thrombocytopenia, he or she gradually tapers the dose and frequency of steroid medication before discontinuing it to avoid adrenal insufficiency or crisis. Eliminating aspirin and NSAIDS will help manage bleeding tendencies. Assessment of the extremities, tonsils, or the lymph nodes is part of a physical examination of a patient and not applicable to corticosteroid therapy.

3. A patient has been diagnosed with thrombocytopenia. What are the primary nursing interventions while instituting corticosteroid therapy in this patient? a) Examine the extremities for redness b) Gradually taper the dose and frequency of medication c) Eliminate aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) d) Palpate the lymph nodes and tonsils every shift

b) Destruction of normally formed red blood cells c) Blood loss d) Abnormal erythrocyte production Pg. 913 Most anemias result from (1) blood loss, (2) inadequate or abnormal erythrocyte production, or (3) destruction of normally formed red blood cells. The most common types include hypovolemic anemia, iron-deficiency anemia, pernicious anemia, folic acid deficiency anemia, sickle cell anemia, and hemolytic anemias. Although each form of anemia has unique manifestations, all share a common core of symptoms. Anemia does not result from infection or inadequate formed white blood cells.

10. A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply. a) Infection b) Destruction of normally formed red blood cells c) Blood loss d) Abnormal erythrocyte production e) Inadequate formed white blood cells

d) Assesses the hemoglobin level Pg. 922 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.

11. 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? a) Holds the epoetin alfa if the BUN is elevated b) Questions the administration of both medications c) Ensures the client has completed dialysis treatment d) Assesses the hemoglobin level

b) Notify the physician Pg. 932 Thrombocytopenia is evidenced by purpura, small hemorrhages in the skin, mucous membranes, or subcutaneous tissues. Bleeding from other parts of the body, such as the nose, oral mucous membrane, and the gastrointestinal tract, also occurs. Internal hemorrhage, which can be severe and even fatal, is possible. This nurse should notify the physician of the suspected disorder.

13. The nurse, caring for a client in the emergency room with a severe nosebleed, becomes concerned when the client asks for a bedpan. The nurse documents the stool as loose, tarry, and black looking. The nurse suspects the client may have thrombocytopenia. What should be the nurse's priority action? a) Stop the nosebleed b) Notify the physician c) Ask someone to clean the bedpan d) Put in an IV line

d) Decreased reticulocytes e) Decreased MCV Pg. 910 In iron deficiency anemia (hypoproliferative anemia), the nurse can expect to find decreased MCV (mean corpuscular volume), and decreased reticulocytes. Fragmented RBCs are found in hemolytic anemias.

14. The nurse cares for a client with iron deficiency anemia. What findings will the nurse expect to find when reviewing the client's CBC results? Select all that apply. a) Fragmented RBCs b) Increased MCV c) Increased reticulocytes d) Decreased reticulocytes e) Decreased MCV

a) Use a disposable razor when shaving Pg. 916 People with aplastic anemia usually have insufficient erythrocytes, leukocytes, and platelets. Encourage behaviors that will lower the risk for bleeding. Avoiding contact with people who are sick reduces the risk of acquiring an infection. Handwashing reduces the risk of acquiring an infection. Anemia can cause fatigue and shortness of breath with even mild exertion.

15. A nurse on a hematology/oncology floor is caring for a client with aplastic anemia. Which would not be included in the client's discharge instructions? a) Use a disposable razor when shaving b) Plan for frequent periods of rest c) Avoid contact with family/friends who are sick d) Encourage frequent handwashing

c) Drink at least 8 glasses of water every day Pg. 920 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.

16. 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? a) Avoid any sports that tire you out b) Avoid any activity that makes you short of breath c) Drink at least 8 glasses of water every day d) Stay on oxygen therapy 24/7

b) Takes over-the-counter iron supplements Pg. 913 When a client receives multiple transfusions and takes iron supplements, there may be a problem with iron overload. It is recommended that clients who are experiencing anemia either avoid or limit alcohol due to interference of alcohol with utilization of essential nutrients. The typical U.S. diet includes 60 grams of protein daily. Clients may be prescribed multivitamins.

17. A client with chronic anemia has received multiple transfusions. Which client action would the nurse be concerned about relative to the client's condition? a) Takes a daily multiple vitamin pill b) Takes over-the-counter iron supplements c) Eliminates use of alcohol d) Takes 60 grams of protein each day

c) Pancytopenia Pg. 916 Pancytopenia is defined as an abnormal decrease in WBCs, RBCs, and platelets. The condition may be congenital or acquired. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of WBCs in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.

18. Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets? a) Thrombocytopenia b) Leukopenia c) Pancytopenia d) Anemia

a) Neutrophil count 1200/microliter c) Platelets 35,000 microliters d) Hemoglobin 7 g/dL Pg. 916 Aplastic anemia causes pancytopenia, or overall decrease to all myeloid stem cell-derived cells. Pancytopenia manifests as neutrophil count less than 1500/microliter, hemoglobin less than 10 g/dL, and platelets less than 50,000/microliter.

19. A nurse cares for a client with aplastic anemia. Which laboratory results will the nurse expect to find with this client? Select all that apply. a) Neutrophil count 1200/microliter b) White blood cell count 10,000/microliter c) Platelets 35,000 microliters d) Hemoglobin 7 g/dL e) Neutrophil count 17,000/microliter

a) Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints Pg. 936 Due to the client's enhanced risk for bleeding, before taking a blood pressure, the nurse asks the client if the use of a blood-pressure cuff has ever produced bleeding under the skin or in the arm joints.

2. A nurse caring for a client who has hemophilia is getting ready to take the client's vital signs. What should the nurse do before taking a blood pressure? a) Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints b) Ask if taking a blood pressure has ever produced pain in the upper arm c) Ask if taking a blood pressure has ever caused bruising in the hand and wrist d) Ask if taking a blood pressure has ever produced the need for medication

a) Wear a medical identification bracelet Pg. 937 Clients with hemophilia should wear a medical identification bracelet about having this disease. Ibuprofen interferes with platelet aggregation and may increase the client's bleeding. A warm bath may lessen pain but increase bleeding. Genetic testing and counseling are not necessary for male clients, because females are the carriers of the genetic material for hemophilia.

21. A young client is diagnosed with a mild form of hemophilia and is experiencing bleeding in the joints with pain. In preparing the client for discharge, what instructions should the nurse provide? a) Wear a medical identification bracelet b) Undergo genetic testing and counseling if the client is male c) Take warm baths to lessen pain d) Take ibuprofen for joint pain

c) Fresh frozen plasma Pg. 936 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.

22. A teenage 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? a) A crystalloid solution such as lactated Ringer's b) A colloid solution such as hetastarch (Hespan) c) Fresh frozen plasma d) Albumin

d) "The child must inherit two defective genes, one from each parent" Pg. 919 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.

23. 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? a) "It is an acquired, not a hereditary disorder" b) "Most likely, the father is the carrier of the gene" c) "The trait is passed down through the mother" d) "The child must inherit two defective genes, one from each parent"

d) It will remove the major site of red blood cell (RBC) destruction Pg. 926-927 For clients with autoimmune hemolytic anemia, if corticosteroids do not produce remission, a splenectomy (i.e., removal of the spleen) may be performed because it removes the major site of RBC destruction.

24. A client admitted to the hospital in preparation for a splenectomy to treat autoimmune hemolytic anemia asks the nurse about the benefits of splenectomy. Which statement best explains the expected effect of splenectomy? a) It will reduce the destruction of platelets by macrophages b) It will increase red blood cell (RBC) production to compensate for blood loss c) It will increase production of platelets by the bone marrow d) It will remove the major site of red blood cell (RBC) destruction

b) Unregulated accumulation of white cells in the bone marrow, which replace normal marrow elements Pg. 911 The term leukemia means "white blood," which is used to describe the neoplastic proliferation of one hematopoietic cell type (granulocytes, monocytes, lymphocytes, and sometimes, erythrocytes and megakaryocytes).

25. When evaluating a patient's symptoms that are consistent with a diagnosis of leukemia, the nurse is aware that all leukemias have which common feature? a) Reduced plasma volume in response to a reduced production of cellular elements b) Unregulated accumulation of white cells in the bone marrow, which replace normal marrow elements c) Compensatory polycythemia stimulated by thrombocytopenia d) Increased blood viscosity, resulting from an overproduction of white cells

d) Abdominal pain Pg. 920 Sickle cell disease (SCD) is an autosomal recessive disorder caused by inheritance of the sickle hemoglobin (HbS) gene. It is associated with severe hemolytic anemia. The HbS gene results in production of a defective hemoglobin molecule that causes the erythrocyte to change shape when exposed to low oxygen tension. The erythrocyte usually has a round, biconcave, pliable shape which in SCD becomes rigid and sickle shaped. Complications of SCD can affect all body systems. Evidence that the client is experiencing a complication in the liver would be the development of abdominal pain. Fatigue and weakness indicate complications involving the central nervous system and heart. Glucose intolerance is not identified as a complication of SCD.

26. The nurse is caring for a client with an exacerbation of sickle cell disease (SCD). Which finding indicates to the nurse that the client is experiencing a liver complication from this condition? a) Weakness b) Glucose intolerance c) Fatigue d) Abdominal pain

b) Health history, such as bleeding, fatigue, or fainting Pg. 916 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. Menstrual history, age, gender, and lifestyle assessments, such as exercise routines and habits, do not directly affect the hematopoietic or lymphatic system.

27. When assessing a client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential? a) Lifestyle assessments, such as exercise routines b) Health history, such as bleeding, fatigue, or fainting c) Menstrual history d) Age and gender

a) Platelet count, prothrombin time, and partial thromboplastin time Pg. 940 The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels aren't used to confirm a diagnosis of DIC.

4. While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters? a) Platelet count, prothrombin time, and partial thromboplastin time b) Fibrinogen level, WBC, and platelet count c) Platelet count, blood glucose levels, and white blood cell (WBC) count d) Thrombin time, calcium levels, and potassium levels

b) Slow the rate of the transfusion and obtain an order for furosemide Pg. 933 The description is consistent with a client who is experiencing circulatory overload. The nurse is to slow the rate of the transfusion and administer a diuretic. Oxygen is administered with a prescription and for severe dyspnea. This option does not allow for the nurse to slow the transfusion. The nurse would still be administering the blood at the current rate of 125 mL/hour. Diphenhydramine (Benadryl) would be prescribed for an allergic reaction. Blood and urine specimens are obtained for acute hemolytic reactions.

5. An older adult client is to receive 2 units of packed red blood cells. During the transfusion of the first unit at 125 mL/hour, the client reports shortness of breath 30 minutes into the process. The client exhibits the vital signs shown in the accompanying table. What is the nurse's best intervention? a) Administer oxygen through nasal cannula at 2 L/minute b) Slow the rate of the transfusion and obtain an order for furosemide

b) A hemolytic allergic reaction caused by an antigen reaction Pg. Hemolytic allergic reactions are fairly common and may cause chills, fever, urticaria, tachycardia, dyspnea, chest pain, hypotension, and other signs of anaphylaxis a few minutes after blood transfusion begins. Although rare, a hemolytic reaction to mismatched blood can occur, triggering a more severe reaction and, possibly, leading to disseminated intravascular coagulation. A hemolytic reaction to Rh-incompatible blood is less severe and occurs several days to 2 weeks after the transfusion. Bacterial contamination of donor blood causes a high fever, nausea, vomiting, diarrhea, abdominal cramps and, possibly, shock.

6. A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the health care provider immediately because the client probably is experiencing which problem? a) A hemolytic reaction to mismatched blood b) A hemolytic allergic reaction caused by an antigen reaction c) A hemolytic reaction to Rh-incompatible blood d) A hemolytic reaction caused by bacterial contamination of donor blood

b) Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit Pg. 919-923 The symptoms indicate impaired tissue perfusion due to a decrease in the oxygen-carrying capacity of the blood. Cardiac status should be carefully assessed. When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly) and by peripheral edema.

7. A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is most appropriate for this client? a) Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients b) Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit c) Fatigue related to decreased hemoglobin and hematocrit d) Risk for falls related to complaints of dizziness

d) Administer the prescribed enoxaparin (Lovenox) Pg. Clients who are prescribed warfarin at home and need to have a major invasive procedure stop taking warfarin prior to the procedure. Low molecular weight heparin, such as enoxaparin, may be used until the procedure is performed. The client will continue with a diet that has a daily consistent amount of vitamin K. The client needs to ambulate frequently throughout the day. Prothrombin (PT) time is monitored, not PTT, when warfarin had been administered.

8. A client is hospitalized 3 days prior to a total hip arthroplasty and reports a high level of pain with ambulation. The client has been taking warfarin at home, which is now discontinued. To prevent the formation of blood clots, which action should the nurse take? a) Monitor partial thromboplastin (PTT) time b) Encourage a diet high in vitamin K c) Have the client limit physical activity d) Administer the prescribed enoxaparin (Lovenox)