Chapter 28: Assessment of Hematologic Function and Treatment Modalities
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." "I could donate my own blood in case I need a transfusion." "My family will donate blood, because it's safer." "I should expect blood withdrawal to take about 15 minutes."
"My family will donate blood, because it's safer." Directed donations from friends and family members are not any safer than those provided by random donors. Withdrawal of 450 mL of blood usually takes about 15 minutes. Specimens from donated blood are tested to detect infections and to identify the specific blood type. Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high.
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 causes abnormally small red blood cells." "The condition is likely caused by a folate deficiency." "The condition is likely caused by a vitamin B12 deficiency."
"The condition is likely caused by a vitamin B12 deficiency." Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12 -intrinsic factor complex is absorbed in the distal ileum. Clients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and the absorption of vitamin B12 may be diminished. Megaloblastic anemia may be caused by a folate deficiency; however, the client's history of gastrectomy indicates the likely cause is a vitamin B12 deficiency. Megaloblastic anemia causes large erythrocytes (RBCs), not small or rigid.
The nurse begins a routine blood transfusion of packed red blood cells (PRBCs) at 1100. To ensure client safety, the unit of blood should be completely transfused by what time? 1530 1115 1600 1500
1500 Administration time for PRBCs should not exceed 4 hours because of the increased risk of bacterial proliferation. For the first 15 minutes, the transfusion should be run slowly- no faster than 5 mL/min.
A client with a history of congestive heart failure has an order to receive 1 unit of packed red blood cells (RBCs). If the nurse hangs the blood at 12:00 pm, by what time must the infusion be completed? 4:00 pm 2:00 pm 6:00 pm 3:00 pm
4:00 pm When packed red blood cells (PRBCs) or whole blood is transfused, the blood should be administered within a 4-hour period because warm room temperatures promote bacterial growth.
A client with Hodgkin disease had a bone marrow biopsy yesterday and reports aching at the biopsy site, rated a 5 (on a 1-10 scale). After assessing the biopsy site, which nursing intervention is most appropriate? Administer acetaminophen 500 mg po, as ordered Reposition the client to a high Fowler position and continue to monitor the pain Notify the physician Administer aspirin (ASA) 325 mg po, as ordered
Administer acetaminophen 500 mg po, as ordered After a marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing. Most clients have no discomfort after a bone marrow biopsy, but the site of a biopsy may ache for 1 or 2 days. Warm tub baths and a mild analgesic agent (e.g., acetaminophen) may be useful. Aspirin-containing analgesic agents should be avoided it the immediate post-procedure period because they can aggravate or potentiate bleeding.
A client in end-stage renal disease is prescribed epoetin alfa and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, what is the priority action taken by the nurse? Assesses the hemoglobin level Questions the administration of both medications Ensures the client has completed dialysis treatment Holds the epoetin alfa if the BUN is elevated
Assesses the hemoglobin level Erythropoietin (epoetin alfa [Epogen]) with oral iron supplements can raise hematocrit levels in the client with end-stage renal disease. The nurse should check the hemoglobin prior to administration of erythropoietin, because too high a hemoglobin level can put the client at risk for heart failure, myocardial infarction, and cerebrovascular accident. Erythropoietin may be administered during dialysis treatments. The BUN will be elevated in the client with end-stage renal disease.
A nursing instructor in a BSN program is preparing for a lecture on disorders of the hematopoietic system. Included in the lecture are conditions caused by reduced levels or absence of blood-clotting proteins. Which of the following is the instructor most likely referring to? Sickle cell disease Pancytopenia Aplastic anemia Coagulopathy
Coagulopathy The term coagulopathy refers to conditions in which a component that is necessary to control bleeding is missing or inadequate.
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. 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? Oral temperature of 97°F Pain and tenderness in calf area Respiratory rate of 10 breaths/minute Crackles auscultated bilaterally
Crackles auscultated bilaterally Increasing the flow rate of a blood transfusion too rapidly can result in circulatory overload. Fluid overload can be manifested by crackles in the lungs. A decreased respiratory rate and decreased temperature are not manifestations of fluid overload. Pain and tenderness in the calf area may indicate a thrombosis which is not as common a manifestation as fluid overload.
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 Decreased total iron-binding capacity Increased mean corpuscular volume
Decreased level of erythropoietin Differentiation of the primitive myeloid stem cell into an erythroblast is stimulated by erythropoietin, a hormone produced primarily by the kidney. If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (i.e., anemia), or with people living at high altitudes with lower atmospheric oxygen concentrations, erythropoietin levels increase. The increased erythropoietin then stimulates the marrow to increase production of erythrocytes. The entire process of erythropoiesis typically takes 5 days (Cook, Ineck, & Lyons, 2011). For normal erythrocyte production, the bone marrow also requires iron, vitamin B12, folate, pyridoxine (vitamin B6), protein, and other factors. A deficiency of these factors during erythropoiesis can result in decreased red cell production and anemia.
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? 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. Inject the morphine into a distal port on the blood tubing. Add the morphine to the blood to be slowly administered.
Disconnect the blood tubing, flush with normal saline, and administer morphine. Never add medications to blood or blood products. The transfusion must be temporarily stopped in order to administer the morphine.
The charge nurse should intervene when observing a new nurse perform which action after a client has suffered a possible hemolytic blood transfusion reaction? Informing the client to leave a urine sample after the client's next void. Disposing of the blood container and tubing in biohazard waste. Documenting the reaction in the client's medical record. Notifying the blood bank of the reaction.
Disposing of the blood container and tubing in biohazard waste. The blood container and tubing should be returned to the blood bank for repeat typing and culture, and the blood bank should be notified of the reaction. A urine sample is collected as soon as possible to detect hemoglobin in the urine. Documenting the client's reaction in the medical record is an appropriate action.
A thin client is prescribed iron dextran intramuscularly. What is most important action taken by the nurse when administering this medication? Injects into the deltoid muscle Rubs the site vigorously Employs the Z-track technique Uses a 23-gauge needle
Employs the Z-track technique 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.
A client receiving a blood transfusion reports shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the health care provider? Ensure there is an oxygen delivery device at the bedside. Remove the intravenous line. Place the client in a recumbent position with legs elevated. Administer prescribed PRN anti-anxiety agent.
Ensure there is an oxygen delivery device at the bedside. The client is exhibiting signs of circulatory overload. After stopping the transfusion and notifying the healthcare provider, the nurse should place the client in a more upright position with the legs dependent to decrease workload on the heart. The IV line is kept patent in case emergency medications are needed. Oxygen and morphine may be needed to treat severe dyspnea. Administering an anti-anxiety agent is not a priority action over ensuring oxygen is available.
A client with severe anemia is admitted to the hospital. Because of religious beliefs, the client is refusing blood transfusions. The nurse anticipates pharmacologic therapy with which drug to stimulate the production of red blood cells? Eltrombopag Filgrastim Epoetin alfa Sargramostim
Epoetin alfa Erythropoietin (epoetin alfa) is an effective alternative treatment for clients with chronic anemia secondary to diminished levels of erythropoietin. This medication stimulates erythropoiesis. Filgratism ( Neupogen) and Sargramostim stimulate granulocytosis( increasing WBC count) , Eltrombopag (Promacta) is used to treat aplastic anemia and thrombocytopenia.
A client with chronic kidney disease has chronic anemia. What pharmacologic alternative to blood transfusion may be used for this client? Erythropoietin GM-CSF Thrombopoietin Eltrombopag
Erythropoietin Erythropoietin (epoetin alfa [Epogen, Procrit]) is an effective alternative treatment for clients with chronic anemia secondary to diminished levels of erythropoietin, as in chronic renal disease. This medication stimulates erythropoiesis.
A patient is undergoing platelet pheresis at the outpatient clinic. What does the nurse know is the most likely clinical disorder the patient is being treated for? Essential thrombocythemia Extreme leukocytosis Renal transplantation Sickle cell anemia
Essential thrombocythemia Platelet pheresis is used to remove platelets from the blood in patients with extreme thrombocytosis or essential thrombocythemia (temporary measure)or in a single-donor platelet transfusion.
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? Renal transplantation Essential thrombocythemia Sickle cell anemia Extreme leukocytosis
Essential thrombocythemia Platelet pheresis is used to remove platelets from the blood in patients with extreme thrombocytosis or essential thrombocythemia (temporary measure)or in a single-donor platelet transfusion.
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? Sickle cell anemia Essential thrombocythemia Extreme leukocytosis Renal transplantation
Essential thrombocythemia Platelet pheresis is used to remove platelets from the blood in patients with extreme thrombocytosis or essential thrombocythemia (temporary measure)or in a single-donor platelet transfusion.
When conducting a health assessment on a client suspected for having a hematological disorder, the nurse should collect which data? Select all that apply. Hair color Ethnicity Dietary intake Medication use Herbal supplements
Ethnicity Dietary intake Medication use Herbal supplements 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 wants to donate blood before his or her abdominal surgery next week. What should be the nurse's first action? Provide the client with a list of the nearest donation centers. Explain the time frame needed for autologous donation. Remind the client to take supplemental iron before donation. Tell the client that 2 units of blood will be needed.
Explain the time frame needed for autologous donation. Preoperative autologous donations are ideally collected 4 to 6 weeks before surgery. The nurse should first explain that time frame to this client. Surgery is scheduled in one week which means that autologous blood donation may not be an option for this client. A list of donation centers can be provided to the client; and even though iron is recommended and 2 units of blood may be suggested, the first action is to tell the client about the needed time frame for donation.
Which term refers to the percentage of blood volume that consists of erythrocytes? Hemoglobin Erythrocyte sedimentation rate (ESR) Differentiation Hematocrit
Hematocrit Hematocrit is the percentage of blood volume consisting of erythrocytes. Differentiation is development of functions and characteristics that differ from those of the parent stem cell. ESR is a laboratory test that measures the rate of settling of RBCs; an elevated rate is indicative of inflammation. Hemoglobin is the iron-containing protein of RBCs.
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? Treatment for osteoarthritis History of renal disease Takes medications for seasonal allergies Previous thyroidectomy
History of renal disease Hemodilution is the removal of 1 to 2 units of blood after induction of anesthesia and replaced with a colloid or crystalloid solution. The blood is then reinfused after the surgery. The purpose of this approach is to reduce the amount of erythrocytes lost during the surgery because the intravenous fluids dilute the concentration of red blood cells and lowers the hematocrit. Hemodilution has been linked to tissue ischemia in the kidneys and would be contraindicated in the client with a history of renal disease. Hemodilution would not be contraindicated for a previous thyroidectomy, treatment for osteoarthritis, or medication used to treat seasonal allergies.
Splenic sequestration is diagnosed in a client admitted with splenomegaly. What is the priority of care for this client? Infection Hyperthermia Hypovolemia Hypertension
Hypovolemia 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 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 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 client's CBC with differential reveals small-shaped hemoglobin molecules. The nurse expects to administer which medication to this client? Vitamin B12 Iron Fresh frozen plasma Folate
Iron 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? Iron chelation therapy Therapeutic phlebotomy Anticoagulation therapy Oxygen therapy
Iron chelation therapy Iron overload is a complication unique to people who have had long-term PRBC transfusions. One unit of PRBCs contains 250 mg of iron. Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. Over time, the excess iron deposits in body tissues and can cause organ damage, particularly in the liver, heart, testes, and pancreas. Promptly initiating a program of iron chelation therapy can prevent end-organ damage from iron toxicity.
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? Supine with head of the bed elevated 30 degrees Lithotomy position Jackknife position Lateral position with one leg flexed
Lateral position with one leg flexed Bone marrow aspiration procedure. The posterior superior iliac crest is the preferred site for bone marrow aspiration and biopsy because no vital organs or vessels are nearby. The patient is placed either in the lateral position with one leg flexed or in the prone position.
Which blood cell type is matched correctly with its function? Leukocyte: Fights infection T lymphocyte: Humoral immunity B lymphocyte: Secretes immunoglobulin Plasma cell: Cell-mediated immunity
Leukocyte: Fights infection 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.
Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following? Kidney Pancreas Large intestine Liver
Liver Albumin is produced by the liver. Albumin is not produced in the pancreas, kidney, or large intestine.
Which term refers to a form of white blood cell involved in immune response? Thrombocyte Granulocyte Spherocyte Lymphocyte
Lymphocyte 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.
Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets? Monocyte Lymphoid stem cell Neutrophil Myeloid stem cell
Myeloid stem cell 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? Neutrophils Eosinophils Basophils Monocytes
Neutrophils Neutrophils, the most abundant type of white blood cell, are the first of the WBCs to respond to infection or inflammation. The normal value is 3,000 to 7,000/cmm (males) and 1,800 to 7,700/cmm (females).
Which is a symptom of severe thrombocytopenia? Dyspnea Inflammation of the tongue Petechiae Inflammation of the mouth
Petechiae Clients with severe thrombocytopenia have petechiae, which are pinpoint hemorrhagic lesions, usually more prominent on the trunk or anterior aspects of the lower extremities.
Which is the major function of neutrophils? Phagocytosis Destruction of tumor cells Rejection of foreign tissue Production of immunoglobulins
Phagocytosis Once a neutrophil is released from the marrow into the circulation, it stays there for only about 6 hours before it migrates into the body tissues to perform its function of phagocytosis (ingestion and digestion of bacteria and particles). Neutrophils die there within 1 to 2 days. T lymphocytes are responsible for rejection of foreign tissue and destruction of tumor cells. Plasma cells produce antibodies called immunoglobulins.
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) Phagocytosis Destruction of tumor cells Rejection of foreign tissue
Phagocytosis The major function of neutrophils is phagocytosis. T lymphocytes are responsible for rejection of foreign tissue and destruction of tumor cells. Plasma cells produce antibodies call immunoglobulin.
A nurse is assisting a client into position prior to bone marrow aspiration. Which position will the nurse place the client prior to the procedure? Supine Knee-chest Trendelenburg Prone
Prone Prior to the bone marrow aspiration, the nurse should place the client in either the prone position or lateral position with one leg flexed. The aspiration usually is performed on the anterior iliac crest. It would not be appropriate for the nurse to place the client in supine, knee-chest, or Trendelenburg positions.
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-positive mother; Rh-positive child Rh-negative mother; Rh-negative child Rh-positive mother; Rh-negative child Rh-negative mother; Rh-positive child
Rh-negative mother; Rh-positive child A mother who is Rh negative and gives birth to an Rh positive child is at greatest risk for a febrile nonhemolytic reaction because exposure to an Rh-positive fetus raises antibody levels in the Rh negative mother. An Rh-negative mother can carry an Rh-negative child without being at greatest risk for a febrile nonhemolytic reaction; however, these mothers are often treated prophylactically. An Rh-positive mother may carry either an Rh-positive or Rh-negative child without increased risk.
The nurse expects which assessment finding of the oral cavity when the client is diagnosed with pernicious anemia? Angular cheilosis Ulcerations of oral mucosa Smooth tongue Enlarged gums
Smooth tongue On physical assessment, the nurse expects to observe a smooth tongue in the client diagnosed with pernicious anemia. Angular cheilosis (ulceration of the corners of the mouth) is seen with anemia. Ulcerations of the oral cavity indicate infection or possible leukemia. Enlarged gums can be indicative of leukemia.
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? Stop the infusion. Call the health care provider. Assess the client's vital signs. Slow the infusion.
Stop the infusion. 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.
Stop the transfusion. Assess the client. Notify the health care provider. Notify the blood bank. Send the tubing and container to the blood bank. It is important for the nurse to take the proper steps when determining the type and severity of a transfusion reaction. The priority action is to stop the infusion and then assess the client. Next, the health care provider will be notified, followed by the blood bank. Finally, the nurse should send the tubing and container to the blood bank for analysis.
Which type of lymphocyte is responsible for cellular immunity? Basophil T lymphocyte Plasma cell B lymphocyte
T lymphocyte T lymphocytes are responsible for delayed allergic reactions, rejection of foreign tissue (e.g., transplanted organs), and destruction of tumor cells. This process is known as cellular immunity. B lymphocytes are responsible for humoral immunity. A plasma cell secretes immunoglobulin. A basophil contains histamine and is an integral part of hypersensitivity reactions.
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? Prothrombin time 12 seconds Temperature of 37.7 degrees Celsius INR 0.9 Blood pressure 132/92
Temperature of 37.7 degrees Celsius Lymphocytopenia is a decrease in the number of lymphocytes. Lymphocytes help to fight foreign invaders, such as infectious organisms. A temperature of 37.7 degree Celsius is a Fahrenheit temperature of 99.9. A low-grade fewer may be indicative of an infection. The other answer choices do not suggest infection and are not the priority concern.
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 experiencing vascular collapse. The client is having an allergic reaction to the blood. The client is having a febrile nonhemolytic reaction. The client is having decrease in tissue perfusion from a shock state.
The client is having a febrile nonhemolytic reaction. The signs and symptoms of a febrile nonhemolytic transfusion reaction are chills (minimal to severe) followed by fever (more than 1°C elevation). The fever typically begins within 2 hours after the transfusion is begun. Although the reaction is not life threatening, the fever, and particularly the chills and muscle stiffness, can be frightening to the client.
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 bone marrow is stimulated by low oxygen levels in the blood and stimulates erythropoietin, maturing the red blood cells. The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells. The kidneys sense low oxygen levels in the blood and stimulate hemoglobin, stimulating the marrow to produce more red blood cells. The brain senses low oxygen levels in the blood and stimulates hemoglobin, which binds to more red blood cells.
The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells. If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (as with anemia), erythropoietin levels increase, stimulating the marrow to produce more erythrocytes (red blood cells).
Place the order of the steps of primary hemostasis in correct order.
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. 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.
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 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? Apply supplemental oxygen to maintain the client's oxygenation. Elevate the client's head of the bed. Use an electric razor when assisting client with shaving. Where a mask when entering the client's room.
Use an electric razor when assisting client with shaving. Petechiae are associated with severe thrombocytopenia, placing the client at risk for bleeding. The nurse should use an electric razor when assisting the client with shaving. Elevating the head of the bed and applying supplemental oxygen would be appropriate for a client with decreased oxygenation. Wearing a mask when entering the client's room would be appropriate for a client with neutropenia, not thrombocytopenia.
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. 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? Assess the client 30 minutes after the start of the initial transfusion Premedicate the client with acetaminophen 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 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 nurse is reviewing a client's morning laboratory results and notes a left shift in the band cells. Based on this result, the nurse can interpret that the client may be developing anemia. has leukopenia. may be developing an infection. has thrombocytopenia.
may be developing an infection. Less mature granulocytes have a single-lobed, elongated nucleus and are called band cells. Ordinarily, band cells account for only a small percentage of circulating granulocytes, although their percentage can increase greatly under conditions in which neutrophil production increases, such as infection. An increased number of band cells is sometimes called a left shift or shift to the left. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of white blood cells in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.
Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called megaloblasts. blast cells. mast cells. monocytes.
megaloblasts. 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.
