Chapter 28 Assessment of Hematologic Function and Treatment Modalities PrepU
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." "The blood is carefully screened, so there is no possibility of you contracting any illness or disease from the blood." "I understand your concern. The blood is carefully screened but is not completely risk free." "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 client with a history of congestive heart failure has an order to receive 1 unit of packed red blood cells (RBCs). If the nurse hangs the blood at 12:00 pm, by what time must the infusion be completed? 2:00 pm 3:00 pm 4:00 pm 6:00 pm
4:00 pm Explanation: When packed red blood cells (PRBCs) or whole blood is transfused, the blood should be administered within a 4-hour period because warm room temperatures promote bacterial growth.
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? Notify the physician Administer aspirin (ASA) 325 mg po, as ordered Administer acetaminophen 500 mg po, as ordered Reposition the client to a high Fowler position and continue to monitor the pain
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.
The nurse should be alert to which adverse assessment finding when transfusing a unit of packed red blood cells (PRBCs) too rapidly? Crackles auscultated bilaterally Respiratory rate of 10 breaths/minute Oral temperature of 97°F Pain and tenderness in calf area
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.
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. Disposing of the blood container and tubing in biohazard waste. Informing the client to leave a urine sample after the client's next void. Documenting the reaction in the client's medical record.
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 thin client is prescribed iron dextran intramuscularly. What is most important action taken by the nurse when administering this medication? Employs the Z-track technique Uses a 23-gauge needle Injects into the deltoid muscle Rubs the site vigorously
Employs the Z-track technique Explanation: When iron medications are given intramuscularly, the nurse uses the Z-track technique to avoid local pain and staining of the skin. The gluteus maximus muscle is used. The nurse avoids rubbing the site vigorously and uses a 18- or 20-gauge needle.
Which term describes the percentage of blood volume that consists of erythrocytes? Hematocrit Differentiation Erythrocyte sedimentation rate (ESR) Hemoglobin
Hematocrit Explanation: Hematocrit is the percentage of blood volume consisting of erythrocytes. Differentiation is the development of functions and characteristics that differ from those of the parent stem cell. ESR is a laboratory test that measures the rate of settling of red blood cells (RBCs); an elevated rate is indicative of inflammation. Hemoglobin is the iron-containing protein of RBCs.
A nurse is caring for a patient who has had a bone marrow aspiration with biopsy. What complication should the nurse be aware of and monitor the patient for? Hemorrhage Blood transfusion reaction Shock Splintering of bone fragments
Hemorrhage Explanation: Hazards of either bone marrow aspiration or biopsy include bleeding and infection. The risk of bleeding is somewhat increased if the patient's platelet count is low or if the patient has been taking a medication (e.g., aspirin) that alters platelet function.
Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets? Myeloid stem cell Lymphoid stem cell Monocyte Neutrophil
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.
Which is a symptom of severe thrombocytopenia? Petechiae Inflammation of the mouth Inflammation of the tongue Dyspnea
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.
The nurse obtains a unit of blood for the client, Donald D. Smith. The name on the label on the unit of blood reads Donald A. Smith. All the other identifiers are correct. What action should the nurse take? Administer the unit of blood Check with the blood bank first and then administer the blood with their permission Refuse to administer the blood Ask the client if he was ever known as Donald A. Smith
Refuse to administer the blood Explanation: To ensure a safe transfusion, all components of the identification must be correct. The nurse should refuse to administer the blood and notify the blood bank about the discrepancy. The blood bank should then take the necessary steps to correct the name on the label on the unit of blood.
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? Assess the client's vital signs. Stop the infusion. Call the health care provider. Slow the infusion.
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.
Which type of lymphocyte is responsible for cellular immunity? B lymphocyte Plasma cell T lymphocyte Basophil
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.
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. Observe for gas bubbles in the unit of packed red blood cells. Verify that the client has signed a written consent form.
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. Reference:
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: Albumin. Globulin. Fibrinogen. Prothrombin.
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 expects which assessment finding when caring for a client with a decreased hemoglobin level? Bright red venous blood. Elevated temperature. Decreased oxygen level. Increased bruising.
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.
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? Add the morphine to the blood to be slowly administered. Inject the morphine into a distal port on the blood tubing. Administer the morphine into the closest tubing port to the client for fast delivery. Disconnect the blood tubing, flush with normal saline, and administer morphine.
Disconnect the blood tubing, flush with normal saline, and administer morphine. Explanation: Never add medications to blood or blood products. The transfusion must be temporarily stopped in order to administer the morphine.
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? Creutzfeldt-Jakob disease Delayed hemolytic reaction Graft-versus-host disease Bacterial contamination
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.
A client is scheduled for surgery to remove an abdominal mass. The nurse knows that which reason hemodilution would be contraindicated as a method to provide blood to the client during the surgery? History of renal disease Previous thyroidectomy 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.
A patient who has long-term packed RBC (PRBC) transfusions has developed symptoms of iron toxicity that affect liver function. What immediate treatment should the nurse anticipate preparing the patient for that can help prevent organ damage? Iron chelation therapy Oxygen therapy Therapeutic phlebotomy Anticoagulation 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 in acute renal failure has been prescribed 2 units of packed red blood cells (PRBCs). The nurse explains to the client that the blood transfusion is most likely needed for which reason? Preparation for likely nephrectomy Increases the effectiveness of dialysis Hypervolemia Lack of erythropoietin
Lack of erythropoietin Explanation: The kidneys produce erythropoietin, a hormone that stimulates red blood cell production. A lack of this hormone is the most likely reason for blood transfusion due to the acute kidney failure. There is no indication for a nephrectomy in this question. A blood transfusion will not necessarily increase the effectiveness of dialysis. Transfusing a client with hypervolemia could lead to circulatory overload.
The nurse is preparing a patient for a bone marrow aspiration and biopsy from the site of the posterior superior iliac crest. What position will the nurse place the patient in? Lateral position with one leg flexed Lithotomy position Supine with head of the bed elevated 30 degrees Jackknife position
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.
Which term refers to a form of white blood cell involved in immune response? Granulocyte Lymphocyte Spherocyte Thrombocyte
Lymphocyte Explanation: Both B and T lymphocytes respond to exposure to antigens. Granulocytes include basophils, neutrophils, and eosinophils. A spherocyte is a red blood cell without central pallor, seen with hemolysis. A thrombocyte is a platelet.
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? Basophils Neutrophils Eosinophils Monocytes
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 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 Fluid support Intubation and mechanical ventilation Intra-aortic balloon pump
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.
The nurse is screening donors for blood donation. Which client is an acceptable donor for blood? Has a history of viral hepatitis as a teenager 10 years ago Received a blood transfusion within 1 year Reports having a cold 1 month ago that resolved quickly Had a dental extraction 2 days ago for caries in a tooth
Reports having a cold 1 month ago that resolved quickly Explanation: Donors must meet certain requirements to be able to donate blood. A client should be in good health, such as the client who had a cold more than 1 month ago that resolved quickly. Those excluded from donating blood have a history of viral hepatitis, report a blood transfusion within 12 months, and had a dental extraction within 72 hours. The reason for exclusion is that they are at increased risk of transmitting an infectious disease.
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-negative mother; Rh-positive child Rh-positive 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 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? 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. This type of exercise increases arterial circulation as it returns to the heart. Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.
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 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.
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 diuretics as prescribed. Discontinue the transfusion. Administer oxygen.
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).
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 I (immediate, anaphylactic) hypersensitivity reaction Type II (cytolytic, cytotoxic) hypersensitivity reaction Type III (immune complex) hypersensitivity reaction Type IV (cell-mediated, delayed) 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.
