Ch 32 Prep U
A nurse is completing a detailed health history and assessment in the electronic medical record (EMR) for a client with a disorder of the hematopoietic system. Which symptom is the most commonly reported in association with hematologic diseases? Blurred vision Dyspnea Extreme fatigue Severe headaches
Extreme fatigue Explanation: When assessing a client with a disorder of the hematopoietic system, it is essential to assess for the most common symptom in hematologic diseases, which is extreme fatigue.
The nurse caring for a client with acute liver failure should expect which assessment finding? Decreased pulse Elevated albumin level Generalized edema Elevated blood pressure
Generalized edema Explanation: People with impaired hepatic function may have low concentrations of albumin, with a resultant decreased in osmotic pressure and the development of edema. Albumin is produced by the liver; the level would be decreased, not increased in liver failure. Albumin is important to maintain fluid balance in the vascular system. Its presence in plasma keeps fluid in the vascular space. With impaired hepatic function and low levels of albumin, the client is more likely to suffer hypotension and tachycardia as a result of hypovolemia.
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 Potassium Hemoglobin Calcium
Iron Explanation: 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.
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? Jackknife position Lithotomy position Supine with head of the bed elevated 30 degrees Lateral position with one leg flexed
Lateral position with one leg flexed Explanation: 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.
What food should the nurse recommend for a client diagnosed with vitamin B12 deficiency? Lean meat Green vegetables Citrus fruit Whole-grain bread
Lean meat Explanation: Vitamin B12 is only found in foods of animal origin. Therefore, whole-grain bread, green vegetables, and citrus fruit do not contain this vitamin.
Which is a symptom of severe thrombocytopenia? Inflammation of the mouth Inflammation of the tongue Dyspnea Petechiae
Petechiae Explanation: Clients with severe thrombocytopenia have petechiae, which are pinpoint hemorrhagic lesions, usually more prominent on the trunk or anterior aspects of the lower extremities.
A client is diagnosed with extreme thrombocytosis. The nurse knows this condition is a result of which elevated blood cell count? Erythocytes Eosinophils Platelets Neutrophils
Platelets Explanation: Extreme thrombocytosis is an elevation in platelets.
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 iron: 100 g/dL Hemoglobin: 16 g/dL Serum ferritin: 15 ng/mL Total iron-binding capacity: 300 g/dL
Serum ferritin: 15 ng/mL Explanation: 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.
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 brain senses low oxygen levels in the blood and produces hemoglobin, which binds to more red blood cells. The bone marrow is stimulated by low oxygen levels in the blood to produce erythropoietin, maturing the 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. The kidneys sense low oxygen levels in the blood and produce hemoglobin, stimulating the marrow to produce more 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. Explanation: If normally functioning kidneys detect low levels of blood oxygen, 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.
Place the order of the steps of primary hemostasis in correct order. The circulating platelets aggregate at the site and adhere to the vessel. The severed blood vessel constricts. An unstable hemostatic plug is formed. Circulating inactive clotting factors convert to active forms.
The severed blood vessel constricts. The circulating platelets aggregate at the site and adhere to the vessel. An unstable hemostatic plug is formed. Circulating inactive clotting factors convert to active forms. Explanation: In primary hemostasis, the severed blood vessel constricts. Circulating platelets aggregate at the site and adhere to the vessel. An unstable hemostatic plug is formed. For the coagulation process to be correctly activated, circulating inactive coagulation factors must be converted to active forms.
The nurse recognizes that the most common cause of iron deficiency anemia in an adult is lack of dietary iron. bleeding. chronic alcoholism. iron malabsorption.
bleeding. Explanation: Iron deficiency in adults generally indicates blood loss (e.g., from bleeding in the gastrointestinal (GI) tract or heavy menstrual flow). Lack of dietary iron is rarely the sole cause of iron deficiency anemia in adults. The source of iron deficiency should be investigated promptly because iron deficiency in an adult may be a sign of bleeding in the GI tract or colon cancer.
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? Inject the morphine into a distal port on the blood tubing. Disconnect the blood tubing, flush with normal saline, and administer morphine. Administer the morphine into the closest tubing port to the client for fast delivery. Add the morphine to the blood to be slowly administered.
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.
The nurse is completing a pretransfusion assessment to determine a female client's history of previous transfusions as well as previous reactions to transfusions. Which is the most important information to obtain from this client before the transfusion? Family history of transfusion reactions Diagnosis Age Number of pregnancies
Number of pregnancies Explanation: The history should include the type of reaction, its manifestations, the interventions required, and whether any preventive interventions were used in subsequent transfusions. The nurse assesses the number of pregnancies a woman has had because a high number can increase her risk of reaction due to antibodies developed from exposure to fetal circulation. Other concurrent health problems should be noted, with careful attention paid to cardiac, pulmonary, and vascular diseases.
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.) Serial chest x-rays Oxygen Intra-aortic balloon pump Fluid support Intubation and mechanical ventilation
Oxygen Fluid support Intubation and mechanical ventilation Explanation: 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.
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 Prothrombin time 12 seconds Blood pressure 132/92 INR 0.9
Temperature of 37.7 degrees Celsius Explanation: 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.
When teaching about the advantages of autologous blood transfusion to a client, the nurse should include which information? Select all that apply. Blood can be transfused to family members and close relatives. It resolves anemia for clients with a hemoglobin less than 11g/dL. If not needed immediately, the blood can be frozen for future use. It is safer for clients with a history of transfusion reactions. The primary advantage is prevention of viral infections.
The primary advantage is prevention of viral infections. It is safer for clients with a history of transfusion reactions. If not needed immediately, the blood can be frozen for future use. Explanation: The primary advantage of autologous transfusions is the prevention of viral infections from another person's blood. Other advantages include safe transfusion for client with a history of transfusion reactions; and if the blood is not required immediately, it can be frozen until the donor needs it. It is the policy of the American Red Cross that autologous blood is transfused only to the donor. Hemoglobin level less than 11g/dL is a contraindication to autologous blood donation.
A client is preparing to leave the blood bank after donating a unit of blood. Which teaching will the nurse provide to the client at this time? "Avoid heavy lifting for several hours." "Increase fluid intake for a week." "Eat healthy meals for a few days." "Avoid smoking for 1 day."'
"Avoid heavy lifting for several hours." Explanation: After a blood donation, the client should be instructed to avoid heavy lifting for several hours. Smoking cessation should be taught, not just one hour after a blood donation. Fluid intake should be increased for 2 days not one week. Healthy meals should be ingested for at least 2 weeks after the donation.
A client who had a splenectomy a year ago is having a routine examination. Which follow-up question will the nurse ask as a priority? "How many fruits and vegetables do you eat each day?" "Have you had any unexplained episodes of bleeding?" "Are you taking more than three medications?" "Have you gotten a flu shot this year?"
"Have you gotten a flu shot this year?" Explanation: The surgical removal of the spleen, or splenectomy, is a possible treatment for some hematologic disorders. Afterwards, the platelet counts should normalize over time. Long-term risks after a splenectomy include a greater likelihood of developing a life-threatening infection. A client without a spleen should receive a vaccine for influenza. The number of medications the client is taking does not increase the likelihood of developing an infection. Unexplained episodes of bleeding should diminish after a splenectomy. The consumption of fruits and vegetables may help with the client's overall immunity but will not directly reduce the client's risk of developing an infection,.
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 agree that you should be concerned with the safety of the blood, but it is important that you have this transfusion." "I understand your concern. The blood is carefully screened but is not completely risk free." "The blood is carefully screened, so there is no possibility of you contracting any illness or disease from the blood." "You will have to decide if refusing the blood transfusion is worth the risk to your health."
"I understand your concern. The blood is carefully screened but is not completely risk free." Explanation: Despite advances in donor screening and blood testing, certain diseases can still be transmitted by transfusion of blood components (Chart 32-4).
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 increase my daily intake of orange vegetables such as sweet potatoes and carrots." "I will eat more dairy products such as milk, yogurt, and ice cream every day." "I will eat a meat source such as chicken or pork with each meal." "I will eat a spinach salad with lunch and dinner."
"I will eat a meat source such as chicken or pork with each meal." Explanation: 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.
The nurse should provide further teaching about post bone-marrow biopsy procedures when the client makes which statement? "I will keep the sterile dressing on until my doctor tells me it's okay to remove it." "I should not take aspirin-containing products for pain relief." "I'll ask someone to drive me home when I awake from general anesthesia." "I may feel some aching in my hip for 1-2 days."
"I'll ask someone to drive me home when I awake from general anesthesia." Explanation: 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.
A preoperative client is discussing blood donation with the nurse. Which statement by the client indicates to the nurse the need for further teaching? "Donated blood is tested for blood type and infections." "My family will donate blood, because it's safer." "I could donate my own blood in case I need a transfusion." "I should expect blood withdrawal to take about 15 minutes."
"My family will donate blood, because it's safer." Explanation: 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.
A client is returning home after having a bone marrow aspiration and biopsy. Which statement indicates that teaching by the nurse has been effective? "I should take aspirin if I have any pain." "I can resume my normal activities." "I can go to the gym to lift weights later." "The area might ache for 1 to 2 days."
"The area might ache for 1 to 2 days." Explanation: Potential complications of either bone marrow aspiration or biopsy include bleeding and infection. After the 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 aspiration, but the site of a biopsy may ache for 1 or 2 days. The client should be instructed to perform no rigorous activity for 1 to 2 days. Aspirin-containing analgesics should be avoided immediately after the procedure as this might cause or aggravate bleeding. Rigorous exercise should be avoided for 1 to 2 days.
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 causes abnormally rigid red blood cells." "The condition is likely caused by a folate deficiency." "The condition is likely caused by a vitamin B12 deficiency." "The condition causes abnormally small red blood cells."
"The condition is likely caused by a vitamin B12 deficiency." Explanation: 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.
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? "One dose is usually all that is needed." "There are no side effects from this medication." "The medication should be given by subcutaneous injection." "Some people may develop low blood pressure."
"The medication should be given by subcutaneous injection." Explanation: 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.
A nurse is caring for a client who will undergo total knee replacement and will have an autologous transfusion. Which statement will the nurse include when teaching the client about the transfusion? "You will likely not need the blood that is donated." "You will be prescribed calcium to replace what is lost during donation." "You typically donate blood 4 to 6 weeks before the surgery." "You typically donate blood the day of the surgery."
"You typically donate blood 4 to 6 weeks before the surgery." Explanation: With autologous donation, a client's own blood may be collected for future transfusion; this is an effective method for orthopedic surgery, where the likelihood of transfusion is high. Preoperative donation is ideally collected 4-6 weeks before surgery. The nurse will not tell the client that the blood will not be needed; orthopedic surgeries often require transfusion of blood. The client will be prescribed iron supplements during the donation time, not calcium.
Which client is not a candidate to be a blood donor according to the American Red Cross? 18-year-old male weighing 52 kg 50-year-old female with pulse 95 beats/minute 86-year-old male with blood pressure 110/70 mm Hg 26-year-old female with hemoglobin 11.0 g/dL
26-year-old female with hemoglobin 11.0 g/dL Explanation: Clients must meet a number of criteria to be eligible as blood donors, including the following: body weight at least 50 kg; pulse rate regular between 50 and 100 bpm; systolic BP 90-100 to 180 mm Hg and diastolic 50 to 100 mm Hg; hemoglobin level at least 12.5 g/dL. There is no upper age limit to donation.
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 mL Explanation: 1 mg/kg X 50 kg = 50 mg then divide by 10 mg/mL = 5 mL
In normal blood, monocytes account for approximately what percentage of the total leukocyte count? 10% 5% 20% 15%
5% Explanation: Monocytes account for approximately 5% of the total leukocyte count. The other percentages are incorrect.
Place the steps of fibrin clot breakdown in correct order. Digestion of fibrinogen and fibrin Release of fibrin degradation products Formation of plasmin Activation of plasminogen
Activation of plasminogen Formation of plasmin Digestion of fibrinogen and fibrin Release of fibrin degradation products Explanation: As an injured vessel is repaired and again covered with endothelial cells, the fibrin clot is no longer needed. Plasminogen is needed to break down the fibrin. The fibrin clot breakdown begins with activation of plasminogen, which forms plasmin. Plasmin acts to digest fibrinogen and fibrin, which releases fibrin degradation products and completes the fibrin clot breakdown.
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? Reposition the client to a high Fowler position and continue to monitor the pain Administer acetaminophen 500 mg po, as ordered Administer aspirin (ASA) 325 mg po, as ordered Notify the physician
Administer acetaminophen 500 mg po, as ordered Explanation: 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.
A client who has idiopathic thrombocytopenia purpura (ITP) has a critically low platelet count. Which nursing intervention will be included in the care plan for this client? Place the client in a private room Administer epoetin alfa Enforce strict contact isolation Administer eltrombopag
Administer eltrombopag Explanation: Thrombopoietin (TPO) is a cytokine that is necessary for the proliferation of megakaryocytes and subsequent platelet formation. Nonimmunogenic second-generation thrombopoietic growth factors (romiplostim and eltrombopag) were recently approved for the treatment of idiopathic thrombocytopenia purpura.
A nurse is assigned to care for a patient with ascites, secondary to cirrhosis. The nurse understands that the fluid accumulation in the peritoneal cavity results from a combination of factors including an alteration in oncotic pressure gradients and increased capillary permeability. Therefore, the nurse monitors the serum level of the plasma protein responsible for maintaining oncotic pressure, which is: Prothrombin. Globulin. Albumin. Fibrinogen.
Albumin. Explanation: Albumin, only produced in the liver, is essential for maintaining oncotic pressure in the vascular system. A decrease in oncotic pressure due to low albumin causes fluid to leak into the peritoneal cavity.
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? Neutropenia Anemia Myelodysplastic syndrome Thrombocytopenia
Anemia Explanation: 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.
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? Pack the wound with half-inch sterile gauze Administer a topical analgesic to control pain at the site Apply pressure over the site for 5-7 minutes Elevate the head of the bed to 45 degrees
Apply pressure over the site for 5-7 minutes Explanation: 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.
A client feels faint and becomes dizzy after donating a unit of blood. Which actions will the nurse perform at this time? Select all that apply. Observe the clent for 30 minutes Assess the client's apical heart rate Assist the client to lie down Place the client's head lower than the knees Provide 1000 mL of fluid stat
Assist the client to lie down Assess the client's apical heart rate Place the client's head lower than the knees Observe the clent for 30 minutes Explanation: Fainting may occur after blood donation and may be related to emotional factors, a vasovagal reaction, or prolonged fasting before donation. Because of the loss of blood volume, hypotension and syncope may occur when the client assumes an erect position. A client who appears pale or reports feeling faint should immediately lie down or sit with the head lowered below the knees. The client should be observed for another 30 minutes. Giving 1000 mL of fluid would be too much fluid at once, and the apical heart rate does not need to be assessed.
Which of the following cells are capable of differentiating into plasma cells? B lymphocytes T lymphocytes Eosinophils Neutrophils
B lymphocytes Explanation: 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.
Which type of leukocyte contains histamine and is an important part of hypersensitivity reactions? Plasma cell B lymphocyte Basophils Neutrophil
Basophils Explanation: 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.
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? Complete blood count Bone marrow aspiration and biopsy Hemoglobin Hematocrit
Bone marrow aspiration and biopsy Explanation: 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.
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? Eltrombopag Romiplostim Epoetin alpha Chelation therapy
Chelation therapy Explanation: 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.
A client with a history of sickle cell anemia has developed iron overload from repeated blood transfusions. What treatment does the nurse anticipate will be prescribed? Chelation therapy White blood cell filter Red blood cell phenotyping Hepatitis B immunization
Chelation therapy Explanation: Chelation therapy is prescribed to treat iron overload. Hepatitis B immunization helps immunize against hepatitis B. Red blood cell phenotyping helps decreased sensitization. A white blood cell filter protects against cytomegalovirus and some sensitization and febrile reactions.
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. This type of exercise increases arterial circulation as it returns to the heart. Isometric exercise programs are inclusive of all muscle groups and have an aerobic effect to increase the heart rate. Isometric exercise decreases the workload of the heart and restores oxygenated blood flow.
Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Explanation: 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.
The nurse should be alert to which adverse assessment finding when transfusing a unit of packed red blood cells (PRBCs) too rapidly? Pain and tenderness in calf area Respiratory rate of 10 breaths/minute Oral temperature of 97°F Crackles auscultated bilaterally
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 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 Increased reticulocyte count Increased mean corpuscular volume Decreased total iron-binding capacity
Decreased level of erythropoietin Explanation: 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.
The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level? Increased bruising. Decreased oxygen level. Elevated temperature. Bright red venous blood.
Decreased oxygen level. Explanation: 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.
When conducting a health assessment on a client suspected for having a hematological disorder, the nurse should collect which data? Select all that apply. Medication use Herbal supplements Dietary intake Ethnicity Hair color
Dietary intake Medication use Ethnicity Herbal supplements Explanation: 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.
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? Provide it to the client before discharge. Release the additional unit for use to the general population. Discard the additional unit. Use the unit for platelets and albumin.
Discard the additional unit. Explanation: 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.
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? Observe for additional symptoms and notify the physician Slow the infusion rate and continue to monitor the client every 15 minutes Discontinue the infusion immediately and notify the physician Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing
Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing Explanation: 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.
The charge nurse should intervene when observing a new nurse perform which action after a client has suffered a possible hemolytic blood transfusion reaction? Notifying the blood bank of the reaction. Documenting the reaction in the client's medical record. Disposing of the blood container and tubing in biohazard waste. Informing the client to leave a urine sample after the client's next void.
Disposing of the blood container and tubing in biohazard waste. Explanation: 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.
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? Remove the intravenous line. Administer prescribed PRN anti-anxiety agent. Place the client in a recumbent position with legs elevated. Ensure there is an oxygen delivery device at the bedside.
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.
A client with chronic kidney disease has chronic anemia. What pharmacologic alternative to blood transfusion may be used for this client? Eltrombopag GM-CSF Erythropoietin Thrombopoietin
Erythropoietin Explanation: 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.
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? Extreme leukocytosis Essential thrombocythemia Renal transplantation Sickle cell anemia
Essential thrombocythemia Explanation: 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.
A client wants to donate blood before his or her abdominal surgery next week. What should be the nurse's first action? Tell the client that 2 units of blood will be needed. Remind the client to take supplemental iron before donation. Provide the client with a list of the nearest donation centers. Explain the time frame needed for autologous donation.
Explain the time frame needed for autologous donation. Explanation: 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.
A nurse administers blood products to a client with Hodgkin disease. During the administration, the nurse notes the client has a fever and diffuse reddened skin rash. From what condition does the nurse suspect the client is suffering? Graft-versus-host disease Bacterial contamination Delayed hemolytic reaction Creutzfeldt-Jakob disease
Graft-versus-host disease Explanation: Graft-versus-hold disease (GVHD) occurs in only severely immunocompromised recipients (such as those with Hodgkin disease). The transfused lymphocytes attack the host lymphocytes or body tissues; symptoms or signs may include fever, diffuse reddened skin rash, nausea, vomiting, and diarrhea. The other answer choices are complications that can occur as a result of blood transfusion; however, these do not present with a diffuse reddened skin rash.
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. Ecchymoses on the skin Petechiae over lower extremities Cloudy urine Conjunctival hemorrhage Headache
Headache Ecchymoses on the skin Conjunctival hemorrhage Petechiae over lower extremities Explanation: 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.
Which term refers to the percentage of blood volume that consists of erythrocytes? Differentiation Hemoglobin Hematocrit Erythrocyte sedimentation rate (ESR)
Hematocrit Explanation: 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.
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? Vitamin B12 deficiency Polycythemia Thrombocytopenia Hemochromatosis
Hemochromatosis Explanation: 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.
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? Previous thyroidectomy History of renal disease Treatment for osteoarthritis Takes medications for seasonal allergies
History of renal disease Explanation: 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.
After withdrawing the needle from blood donor's arm, the site begins to bleed excessively. What is the nurse's first action? Apply a tourniquet above the antecubital fossa. Hold firm pressure on the venipuncture site. Assist the client into an erect position. Lower the arm below the level of the heart.
Hold firm pressure on the venipuncture site. Explanation: Excessive bleeding at the venipuncture site may be caused by not applying enough pressure at the site. Applying a tourniquet will exacerbate the bleeding. After applying pressure, the arm should be raised above heart level. Helping the client into an erect position will not help stop the bleeding.
Splenic sequestration is diagnosed in a client admitted with splenomegaly. What is the priority of care for this client? Infection Hyperthermia Hypertension Hypovolemia
Hypovolemia Explanation: If the spleen is enlarged, a greater proportion of red cells and platelets can be sequestered. With less red blood cells in circulation, the client can become hypovolemic resulting in shock. Decreased white blood cells in circulation, not red blood cells, increases the chance of infection. Decreased circulatory volume results in hypotension, not hypertension. Hyperthermia is not a result of decreased red blood cells in circulation.
A client is being treated for chronic myeloid leukemia (CML). Which medication will the nurse expect to be prescribed for this client? Prednisone Dilantin Calcium carbonate Imatinib mesylate
Imatinib mesylate Explanation: 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.
A client is being treated for idiopathic thrombocytopenia purpura. Which blood component will the nurse expect to be prescribed to the client? Factor IX Immunoglobulin Plasma albumin Platelets
Immunoglobulin Explanation: Immune globulin is a concentrated solution of the antibody immunoglobulin G (IgG), prepared from large pools of plasma. Intravenous immunoglobulin is used as a treatment for patients with certain autoimmune disorders, such as idiopathic thrombocytopenic purpura. Platelets are used in clients who are actively bleeding. Factor IX is used to treat hemophilia B. Plasma albumin is used to treat clients in hypovolemic shock.
A client is receiving platelets. In order to decrease the risk of circulatory overload in this client, what action should the nurse take? Infuse each unit over 30-60 minutes per client tolerance. Administer each unit slowly over 3-4 hours. Monitor vital signs closely before transfusion and once per shift. Flush the intravenous line with a liter of saline between units.
Infuse each unit over 30-60 minutes per client tolerance. Explanation: Infuse each unit of FFP over 30-60 minutes per client tolerance. Platelet clumping will occur if administered too slowly. Vital signs should be monitored before and throughout the transfusion, not just once per shift. A liter of saline is too large an amount to flush the intravenous line and would contribute to fluid overload.
A client scheduled for hip replacement surgery did not have enough time to have autologous donations completed. The nurse knows that which action will be performed if the client requires blood during the surgery? Direct donation Intraoperative blood salvage Hemodilution Plasmapheresis
Intraoperative blood salvage Explanation: Intraoperative blood salvage is a method for clients who are unable to donate blood before surgery and are having an orthopedic surgery. During the procedure, blood lost into a sterile cavity is suctioned into a cell-saver machine where is it is washed, filtered, and then infused into the client. Hemodilution is a transfusion method where 1 to 2 units of blood are removed after the induction of anesthesia and then reinfused after surgery. This approach has been linked to tissue ischemia of the kidneys. Plasmapheresis is the removal of plasma proteins and used for hyperviscosity syndromes and to treat some renal and neurologic diseases. It would not be applicable after joint replacement surgery. Direct donation is not routinely accepted by blood centers and would not be an action if the client requires blood during the surgery.
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? Potassium Calcium Iron White blood cell count
Iron Explanation: 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.
The client's CBC with differential reveals small-shaped hemoglobin molecules. The nurse expects to administer which medication to this client? Vitamin B12 Iron Folate Fresh frozen plasma
Iron Explanation: With iron deficiency, the erythrocytes produced by the marrow are small and low in hemoglobin. Vitamin B12 and folate deficiencies are characterized by the production of abnormally large erythrocytes. Fresh frozen plasma are infused due to a low platelet level, not light-colored hemoglobin.
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? Anticoagulation therapy Iron chelation therapy Therapeutic phlebotomy Oxygen therapy
Iron chelation therapy Explanation: 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.
A client reports feeling faint after donating blood. What is the nurse's best action? Assist the client into high-Fowler's position. Place the client in Trendelenburg position. Keep client in recumbent position to rest. Ambulate client with assistance.
Keep client in recumbent position to rest. Explanation: 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.
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 Nuts and seeds Organic foods Lean meats Animal fats
Leafy green vegetables Lean meats Nuts and seeds Explanation: 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.
Which blood cell type is matched correctly with its function? Plasma cell: Cell-mediated immunity T lymphocyte: Humoral immunity Leukocyte: Fights infection B lymphocyte: Secretes immunoglobulin
Leukocyte: Fights infection Explanation: Various blood cell types have unique, major functions. Leukocytes fight infection, T lymphocytes are integral in cell-mediated immunity, plasma cells secrete immunoglobulin, and B lymphocytes are integral in humoral immunity.
Which nursing intervention should be incorporated into the plan of care for a client with impaired liver function and a low albumin concentration? Implement neutropenic precautions Apply prolonged pressure to needle sites or other sources of external bleeding Monitor for edema at least once per shift Monitor temperature at least once per shift
Monitor for edema at least once per shift Explanation: Albumin is particularly important for the maintenance of fluid balance within the vascular system. Capillary walls are impermeable to albumin, so its presence in the plasma creates an osmotic force that keeps fluid within the vascular space. Clients with impaired hepatic function may have low concentrations of albumin, with a resultant decrease in osmotic pressure and the development of edema.
Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets? Lymphoid stem cell Myeloid stem cell Neutrophil Monocyte
Myeloid stem cell Explanation: The myeloid stem cell is responsible not only for all nonlymphoid white blood cells, 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. A neutrophil is a fully mature WBC capable of phagocytosis.
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? Monocytes Basophils Eosinophils Neutrophils
Neutrophils Explanation: 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).
A client develops a hemolytic reaction to a blood transfusion. What actions should the nurse take after this occurs? Select all that apply. Begin iron chelation therapy Administer diphenhydramine Obtain appropriate blood specimens Collect a urine sample to detect hemoglobin Document the reaction according to policy
Obtain appropriate blood specimens Collect a urine sample to detect hemoglobin Document the reaction according to policy Explanation: If a hemolytic transfusion reaction or bacterial infection is suspected, the nurse does the following: obtains appropriate blood specimens from the client; collects a urine sample as soon as possible to detect hemoglobin in the urine; and documents the reaction according to the institution's policy.
A nurse cares for an older adult client with acute myeloid leukemia (AML). What concept does the nurse understand leads to the increased risk of an older adult acquiring myeloid malignancies such as AML? Older adults are exposed to more infectious disease over time. Older adults acquire damage to the bone marrow over time. Older adults have an increasing number of leukocytes over time. Older adults acquire damage to the DNA of stem cells over time.
Older adults acquire damage to the DNA of stem cells over time. Explanation: Older adults acquire damage to the DNA of stem cells over time, increasing the chance of myeloid malignancies such as AML. The damage over time is to the stem cells themselves, not the bone marrow. Exposure to infectious disease does not increase the chance of developing myeloid malignancies.
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? Lactated Ringer's solution Normal saline solution Fresh frozen plasma Packed red blood cells (RBCs)
Packed red blood cells (RBCs) Explanation: 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.
The nurse reviewing laboratory results of a client recovering from abdominal surgery notices an elevated number of reticulocytes. What is the nurse's first action? Perform an abdominal assessment. Notify the healthcare provider. Hold the prescribed blood transfusion. Document the findings as expected results.
Perform an abdominal assessment. Explanation: The bone marrow can release immature forms of erythrocytes, called reticulocytes, into the circulation in response to bleeding. The nurse should assess this client's abdomen, because the client is recovering from abdominal surgery. The nurse should assess and gather more data before notifying the healthcare provider. A blood transfusion would not be held if internal bleeding is expected.
Which is the major function of neutrophils? Production of immunoglobulins Phagocytosis Destruction of tumor cells Rejection of foreign tissue
Phagocytosis Explanation: 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.
Under normal conditions, the adult bone marrow produces approximately 70 billion neutrophils. What is the major function of neutrophils? Production of antibodies called immunoglobulin (Ig) Destruction of tumor cells Phagocytosis Rejection of foreign tissue
Phagocytosis Explanation: 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.
The nurse is administering 2 units of packed RBCs to an older adult patient who has a bleeding duodenal ulcer. The patient begins to experience difficulty breathing and the nurse assesses crackles in the lung bases, jugular vein distention, and an increase in blood pressure. What action by the nurse is necessary if the reaction is severe? (Select all that apply.) Continue the infusion but slow the rate down. Place the patient in an upright position with the feet dependent. Administer oxygen. Discontinue the transfusion. Administer diuretics as prescribed.
Place the patient in an upright position with the feet dependent. Administer diuretics as prescribed. Discontinue the transfusion. Administer oxygen. Explanation: Signs of circulatory overload include dyspnea, orthopnea, tachycardia, and sudden anxiety. Jugular vein distention, crackles at the base of the lungs, and an increase in blood pressure can also occur. If the transfusion is continued, pulmonary edema can develop, as manifested by severe dyspnea and coughing of pink, frothy sputum. If fluid overload is mild, the transfusion can often be continued after slowing the rate of infusion and administering diuretics. However, if the overload is severe, the patient is placed upright with the feet in a dependent position, the transfusion is discontinued, and the primary provider is notified. Oxygen and morphine may be needed to treat severe dyspnea (see Chapter 29).
The client is planned to have a splenectomy. The nurse should prepare which medication to administer to this client? Pneumococcal vaccine Immunoglobulin G (IgG) Factor VIII Aspirin
Pneumococcal vaccine Explanation: Without a spleen, the client's risk of infection is greatly increased. The pneumococcal vaccine should be administered, preferable before splenectomy. Aspirin should not be administered due to the increased risk of bleeding. IgG is administered to client with increased chance of bacterial infections but is not routinely given to client undergoing splenectomy, as is the pneumococcal vaccine. Factor VII is given to treat bleeding disorders.
The nurse is completing a physical assessment on a client's lymphatic system. The nurse should palpate for enlarged nodes in which areas? Select all that apply. Neck Spinal Submental Popliteal Inguinal
Popliteal Inguinal Submental Neck Explanation: Palpable lymph node areas include: popliteal, inguinal, submental, and neck. The spinal region does not contain palpable lymph nodes.
Place the clotting cascade in the correct order: FIBRIN PROTHROMBIN FIBRINOGEN THROMBIN PROTHROMBIN ACTIVATOR
Prothrombin activator Prothrombin Thrombin Fibrinogen Fibrin Explanation: There is an intrinsic and extrinsic clotting pathway with various clotting factors unique to each. However, the common clotting cascade is the end result in both pathways. Prothrombin activator form prothrombin, which forms thrombin, then fibrinogen, and finally fibrin.
The nurse is working at a blood donation clinic. What teaching should the nurse provide to the donor immediately after blood donation? Hold the involved arm below the heart. Remain for observation after eating and drinking. Sit up promptly after the needle is removed. Remove the band-aid after 5 minutes.
Remain for observation after eating and drinking. Explanation: 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.
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-negative child Rh-positive mother; Rh-negative child Rh-positive mother; Rh-positive child Rh-negative mother; Rh-positive child
Rh-negative mother; Rh-positive child Explanation: 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.
The nurse learns that a client has a family history of a hematologic condition. Which assessment findings indicate to the nurse that the client needs additional assessment for the condition? Select all that apply. Report of fatigue Diffuse mild abdominal pain Report of frequent nosebleeds Peripheral edema Scattered bruises
Scattered bruises Report of fatigue Diffuse mild abdominal pain Report of frequent nosebleeds Explanation: A careful health history and physical assessment can provide important information related to a client's known or potential hematologic diagnosis. Because many hematologic disorders are more prevalent in certain ethnic groups, assessments of ethnicity and family history are useful. The client's family history of a hematologic condition would guide the nurse during the assessment. Findings associated with a hematologic condition include evidence of bleeding such as scattered bruises. Fatigue is the most common symptom of a hematologic condition. Additional symptoms include abdominal pain and report of frequent nosebleeds. Peripheral edema is not identified as a specific symptom of a hematologic condition.
A client with myelodysplastic syndromes (MDS) routinely takes oral chelation therapy. Which assessment findings indicate to the nurse that the client is experiencing side effects from this treatment? Select all that apply. Skin rash Hypertension Vomiting Diarrhea Abdominal cramping
Skin rash Diarrhea Abdominal cramping Explanation: Chelation therapy is a process that is used to remove excess iron acquired from chronic transfusions. Side effects from oral chelators include skin rash, diarrhea, and abdominal cramping. Hypertension and vomiting are not side effects of chelation therapy.
Place the following procedural steps in order for transfusing a unit of packed red blood cells (PRBCs). Obtain the unit of PRBCs from the blood bank. Double check the labels with another nurse to ensure correct ABO group and Rh type. Start an intravenous line. Initiate the blood transfusion within 30 minutes of receipt. Monitor closely for signs of a transfusion reaction.
Start an intravenous line. Obtain the unit of PRBCs from the blood bank. Double check the labels with another nurse to ensure correct ABO group and Rh type. Initiate the blood transfusion within 30 minutes of receipt. Monitor closely for signs of a transfusion reaction. Explanation: The nurse should first start an intravenous line, obtain the PRBCs, double check labels, start the transfusion, and then monitor for a reaction.
A nurse is transfusing whole blood to a client with impaired renal function. During the transfusion, the client tells the nurse, "I feel very short of breath all of a sudden." What is the nurse's primary action? Slow the infusion. Stop the infusion. Call the health care provider. Assess the client's vital signs.
Stop the infusion. Explanation: A client with impaired renal function is at increased risk for transfusion-associated circulatory overload (TACO). Signs of circulatory overload include dyspnea, orthopnea, tachycardia, an increase in blood pressure, and sudden anxiety. If the symptoms are mild, the nurse may be able to slow the infusion and administer diuretics; however, sudden shortness of breath should clue the nurse to immediately stop the infusion and sit the client upright with feet dangling. Next, the nurse will notify the health care provider after normal saline is infused into the site. Only after stopping the infusion will the nurse obtain the client's vital signs.
Place the following steps in order when determining the type and severity of a transfusion reaction. Use all options. Assess the client. Stop the transfusion. Notify the health care provider. Send the tubing and container to the blood bank. Notify the blood bank.
Stop the transfusion. Assess the client. Notify the health care provider. Notify the blood bank. Send the tubing and container to the blood bank. Explanation: 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.
Which type of lymphocyte is responsible for cellular immunity? Basophil Plasma cell B lymphocyte T lymphocyte
T lymphocyte Explanation: 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.
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? Monocytes T lymphocytes Leukocytes B lymphocytes
T lymphocytes Explanation: 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.
A client who received 2 units of packed red blood cells 3 hours ago reports a new onset of dyspnea. Which additional assessment findings indicate to the nurse that the client is developing transfusion-related acute lung injury (TRALI)? Select all that apply. Oxygen saturation 88% on room air Temperature 102oF (38.8oC) Jugular vein distention Bilateral lower extremity edema Blood pressure 78/50 mm Hg
Temperature 102oF (38.8oC) Blood pressure 78/50 mm Hg Oxygen saturation 88% on room air Explanation: TRALI is a potentially fatal, idiosyncratic reaction that is defined as the development of acute lung injury occurring within 6 hours after the blood transfusion. Onset is abrupt (usually within 6 hours of transfusion, often within 2 hours). Signs and symptoms include acute shortness of breath, hypoxia, oxygen saturation less than 90%, hypotension and a fever. Jugular vein distention and bilateral lower extremity edema are associated with transfusion-associated circulatory overload.
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 decrease in tissue perfusion from a shock state. The client is having a febrile nonhemolytic reaction. The client is experiencing vascular collapse. The client is having an allergic reaction to the blood.
The client is having a febrile nonhemolytic reaction. Explanation: 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.
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 three cell types—erythrocytes, leukocytes, and platelets—can resume production of stem cells. Fat found in yellow bone marrow can be replaced by active marrow when more blood cell production is required. The remaining stem cells have the ability to continue with the process of self-replication, creating an endless supply. The liver and spleen can resume production of blood cells through extramedullary hematopoiesis.
The liver and spleen can resume production of blood cells through extramedullary hematopoiesis. Explanation: 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.
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 limited supply throughout the life cycle. Lymphoid stem cells produce lymphocytes. There is a continuous supply throughout the life cycle. Myeloid stem cells produce erythrocytes. They have the ability to self-replicate.
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. Explanation: 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).
When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea, and itching. When urticaria, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction? Type IV (cell-mediated, delayed) hypersensitivity reaction Type II (cytolytic, cytotoxic) hypersensitivity reaction Type III (immune complex) hypersensitivity reaction Type I (immediate, anaphylactic) hypersensitivity reaction
Type II (cytolytic, cytotoxic) hypersensitivity reaction Explanation: ABO incompatibility, such as from an incompatible blood transfusion, is a type II hypersensitivity reaction. Transfusions of more than 100 ml of incompatible blood can cause severe and permanent renal damage, circulatory shock, and even death. Drug-induced hemolytic anemia is another example of a type II reaction. A type I hypersensitivity reaction occurs in anaphylaxis, atopic diseases, and skin reactions. A type III hypersensitivity reaction occurs in Arthus reaction, serum sickness, systemic lupus erythematosus, and acute glomerulonephritis. A type IV hypersensitivity reaction occurs in tuberculosis, contact dermatitis, and transplant rejection.
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. Apply supplemental oxygen to maintain the client's oxygenation. Elevate the client's head of the bed. Where a mask when entering the client's room.
Use an electric razor when assisting client with shaving. Explanation: 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.
The client is to receive a unit of packed red blood cells. What is the nurse's first action? Check the label on the unit of blood with another registered nurse. Ensure that the intravenous site has a 20-gauge or larger needle. Verify that the client has signed a written consent form. Observe for gas bubbles in the unit of packed red blood cells.
Verify that the client has signed a written consent form. Explanation: All the options are interventions the nurse will do to ensure the blood transfusion is safe. The question asks about the first action of the nurse. The first action would be verifying that the client has signed a written consent form. Then, the nurse would ensure the intravenous site has a 20-gauge or larger needle. The nurse would proceed to obtain the unit of blood, check the blood with another registered nurse, and observe for gas bubbles in the unit of blood.
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? Premedicate the client with acetaminophen Assess the client 30 minutes after the start of the initial transfusion Administer the blood as soon as it arrives Verify the client's identity according to hospital policy
Verify the client's identity according to hospital policy Explanation: 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.
A client arrives for an appointment at the community blood bank to donate a unit of B- blood. The nurse knows that which reasons may be why the client cannot donate at this time? Select all that apply. Hemoglobin 11.3 g/dL (113 g/L) Age 64 Returned from a trip to Africa a month ago Weight 48 kg (105.6 lbs.) Received a blood transfusion for surgery 2 years ago
Weight 48 kg (105.6 lbs.) Hemoglobin 11.3 g/dL (113 g/L) Returned from a trip to Africa a month ago Explanation: To protect both the donor and the recipients, all prospective donors are examined and interviewed before they are allowed to donate their blood. Minimal requirements to donate blood include a body weight of at least 50 kg (110 lbs.). The hemoglobin level is to be at least 12.5 g/dL (125 g/L). Travel outside of any country within the past 3 years needs to be reviewed before a donation is accepted. The client is underweight, has a low hemoglobin level, and returned form a trip abroad a month ago. The client will need to wait before donating at this time. There is no upper age limit to donation. Prospective donors who received a blood transfusion must wait 12 months before a donation is accepted. The client received a blood transfusion 2 years ago for surgery, which would not prevent the donation of blood.
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 has thrombocytopenia. may be developing an infection. may be developing anemia. has leukopenia.
may be developing an infection. Explanation: 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.
Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called: monocytes. blast cells. megaloblasts. mast cells.
megaloblasts. Explanation: Megaloblasts are abnormally large erythrocytes. Blast cells are primitive WBCs. Mast cells are cells found in connective tissue involved in defense of the body and coagulation. Monocytes are large WBCs that become macrophages when they leave the circulation and move into body tissues.
