Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders

A client's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC? "DIC is a complication of an autoimmune disease that attacks the body's own cells." "DIC is caused when hemolytic processes destroy erythrocytes." "DIC occurs when the immune system attacks platelets and causes massive bleeding." "DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs."

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

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

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

A client with sickle cell crisis is admitted to the hospital in severe pain. While caring for the client during the crisis, which is the priority nursing intervention? Encouraging the client to ambulate immediately Administering and evaluating the effectiveness of opioid analgesics Limiting the client's intake of oral and IV fluids Limit foods that contain folic acid

Administering and evaluating the effectiveness of opioid analgesics Explanation: The priority nursing intervention is to manage the acute pain. Client-controlled analgesia is frequently used in the acute care setting. A patient with sickle cell crisis experiences severe extreme pain, the use of IV fluids and oral intake is need to hydrate the patient, the patient is initially placed on bed rest during the crisis due to extreme fatigue. The patient must continue to ingest folic acid and are placed on a daily folic acid supplement .

Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia? Eliminate direct contact with others who are infectious Monitor temperature at least once per shift Apply prolonged pressure to needle sites or other sources of external bleeding Implement neutropenic precautions

Apply prolonged pressure to needle sites or other sources of external bleeding Explanation: For a client with leukemia, the nurse should apply prolonged pressure to needle sites or other sources of external bleeding. Reduced platelet production results in a delayed clotting process and increases the potential for hemorrhage. Implementing neutropenic precautions and eliminating direct contact with others are interventions to address the risk for infection.

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 Ensures the client has completed dialysis treatment Holds the epoetin alfa if the BUN is elevated Questions the administration of both medications

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

The nurse is caring for a client with type 2 diabetes who take metformin to manage glucose levels. The nurse recognizes the client may be most at risk for which vitamin deficiency? B12 Folate A C

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

When teaching a client with iron deficiency anemia about appropriate food choices, the nurse encourages the client to increase the dietary intake of which foods? Beans, dried fruits, and leafy, green vegetables Fruits high in vitamin C, such as oranges and grapefruits Berries and orange vegetables Dairy products

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

The nurse is educating a client about iron supplements. The nurse teaches that what vitamin enhances the absorption of iron? C D A E

C Explanation: Vitamin C facilitates the absorption of iron. Therefore, iron supplements should be taken with a glass of orange juice or a vitamin C tablet to maximize absorption.

A client reports feeling tired, cold, and short of breath at times. Assessment reveals tachycardia and reduced energy. What would the nurse expect the physician to order? ECG chest radiograph CBC antibiotic

CBC Explanation: Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. A CBC would be ordered.

A patient with end-stage kidney disease (ESKD) has developed anemia. What laboratory finding does the nurse understand to be significant in this stage of anemia? Calcium level of 9.4 mg/dL Potassium level of 5.2 mEq/L Magnesium level of 2.5 mg/dL Creatinine level of 6 mg/100 mL

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

A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor? Increased reticulocyte count Decreased total iron-binding capacity Increased mean corpuscular volume Decreased level of erythropoietin

Decreased level of erythropoietin Explanation: As renal function decreases, erythropoietin, which is produced by the kidney, also decreases. Because erythropoietin is produced outside the kidney, some erythropoiesis continues, even in patients whose kidneys have been removed. However, the number of red blood cells produced is small and the degree of erythropoiesis is inadequate.

The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions? Do not take medication with orange juice because it will delay absorption of the iron. Discontinue the use of iron if your stool turns black. Iron may cause indigestion and should be taken with an antacid such as Mylanta. Dilute the liquid preparation with another liquid such as juice and drink with a straw.

Dilute the liquid preparation with another liquid such as juice and drink with a straw. Explanation: Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid staining the teeth. Avoid taking iron simultaneously with an antacid, which interferes with iron absorption. Drink orange juice or take other forms of vitamin C with iron to promote its absorption. Expect iron to color stool dark green or black.

Which client is most at risk for developing disseminated intravascular coagulation (DIC)? A client admitted with suspected cocaine overdose A client with heart failure and renal failure A client with an amniotic fluid embolism A client with a stage IV pressure ulcer

A client with an amniotic fluid embolism Explanation: The client with the amniotic fluid embolism is at greatest risk for developing DIC. Other risk factors for developing DIC include trauma, cancer, shock, and sepsis. Possible cocaine overdose, a stage IV pressure ulcer, and heart failure and renal failure aren't risk factors for DIC.

When assessing a client with anemia, which assessment is essential? Health history, including menstrual history in women Family history Lifestyle assessments, such as exercise routines Age and gender

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

A patient with End Stage Kidney Disease is taking recombinant erythropoietin for the treatment of anemia. What laboratory study does the nurse understand will have to be assessed at least monthly related to this medication? Potassium level Hemoglobin level Creatinine level Folate levels

Hemoglobin level Explanation: When using recombinant erythropoietin, the hemoglobin must be checked at least monthly (more frequently until a maintenance dose is established) and the dose titrated to ensure the hemoglobin level does not exceed 12 g/dL.

The thalassemias are a group of hereditary anemias characterized by which of the following? Select all that apply. Hypochromia Extreme microcytosis Anemia Thrombocytopenia Hemolysis

Hypochromia Extreme microcytosis Hemolysis Anemia Explanation: The thalassemias are a group of hereditary anemias characterized by hypochromia, extreme microcytosis, destruction of blood elements (hemolysis), and variable degrees of anemia. Thrombocytopenia is not associated with thalassemias.

A nurse provides nutritional information for a patient diagnosed with an iron-deficiency anemia. What education should the nurse provide? Take an iron supplement with meals to reduce gastric irritation. Increase the intake of green, leafy vegetables. Decrease the intake of citrus fruits because they interfere with iron absorption. Decrease the intake of high-fat red meats, especially organ meats.

Increase the intake of green, leafy vegetables. Explanation: Leafy greens, such as spinach, kale, swiss chard, collard and beet greens contain between 2.5-6.4 mg of iron per cooked cup. Clients should be encouraged to consume more green, leafy vegetables. Red meats, especially organ meats, are iron-rich foods and the client should not be discouraged from eating them. Vitamin C sources (citrus fruit and juices) enhance the absorption of iron, which should be taken 1 hour before or 2 hours after a meal.

A client with a diagnosis of pernicious anemia comes to the clinic reporting of numbness and tingling in his arms and legs. What do these symptoms indicate? Loss of vibratory and position senses Insufficient intake of dietary nutrients Neurologic involvement Severity of the disease

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

A client with a diagnosis of pernicious anemia comes to the clinic and reports numbness and tingling in the arms and legs. What do these symptoms indicate? Loss of vibratory and position senses Insufficient intake of dietary nutrients Severity of the disease Neurologic involvement

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

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

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

A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse? Inform the client that the position must be changed, and then you will give her pain medication and omit the bath. Inform the client that she will feel better after receiving a bath and clean sheets. Inform the client that the bath and positioning is an important part of client care and will be done right after pain medication administration. Obtain the pain medication and delay the bath and position change until the medication reaches its peak.

Obtain the pain medication and delay the bath and position change until the medication reaches its peak. Explanation: When pain is severe, the nurse delays position changes and bathing until an administered analgesic has reached its peak concentration level and the client is experiencing maximum pain relief. Pain medication should never be delayed to assist in the control of the level of pain. Pain will not be relieved by a bath and clean sheets, only analgesics at this point in the client's illness.

While assessing a client, the nurse will recognize what as the most obvious sign of anemia? Jaundice Flow murmurs Pallor Tachycardia

Pallor Explanation: On physical examination, pallor is the most common and obvious sign of anemia. Other findings may include tachycardia and flow murmurs. Patients with hemolytic anemia may exhibit jaundice and splenomegaly.

A young mother with a 2 year old and a 6 month old is experiencing fatigue related to anemia. The client states that she is having difficulty performing the activities needed for her job, family, and home. With what task is it most appropriate for the nurse to assist the client? Requesting a leave of absence from her job. Obtaining assistance from someone to help with cleaning in the home. Finding a babysitter to take care of her children. Prioritizing and balancing activities and rest.

Prioritizing and balancing activities and rest. Explanation: Fatigue is the most common symptom and complication of anemia. The nurse should assist the client to prioritize activities and to establish a balance between activity and rest that the client finds acceptable. With the other options, the nurse is jumping to conclusions that these things will help the client.

Which type of hemolytic anemia is categorized as inherited disorder? Cold agglutinin disease Sickle cell anemia Hypersplenism Autoimmune hemolytic anemia

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

A client is prescribed 325 mg/day of oral ferrous sulfate. What does the nurse include in client teaching? Take with dairy products Decrease intake of dietary fiber Take 1 hour before breakfast Decrease intake of fruits and juices

Take 1 hour before breakfast Explanation: Instructions the nurse will provide for the client taking oral ferrous sulfate is to administer the medication on an empty stomach. Instructions also include that there is decreased absorption of iron with food, particularly dairy products. The client is to increase vitamin C intake (fruits, juices, tomatoes, broccoli), which will enhance iron absorption. The client is to also increase foods high in fiber to decrease risk of constipation.

A client is treated for anemia. What is the nurse's best understanding about the correlation between anemia and the client's iron stores? There is a weak correlation between iron stores and hemoglobin levels. There is a strong correlation between iron stores and hemoglobin levels. There is an inverse relationship between iron stores and hemoglobin levels. There is a strong correlation between iron stores and hemoglobin characteristics.

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

After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm3. What term should the nurse use to describe this low platelet count? Anemia Neutropenia Thrombocytopenia Leukopenia

Thrombocytopenia Explanation: A normal platelet count is 140,000 to 400,000/mm3 in adults. Chemotherapeutic agents produce bone marrow depression, resulting in reduced red blood cell counts (anemia), reduced white blood cell counts (leukopenia), and reduced platelet counts (thrombocytopenia). Neutropenia is the presence of an abnormally reduced number of neutrophils in the blood and is caused by bone marrow depression induced by chemotherapeutic agents.

Which medication is the antidote to warfarin? Aspirin Clopidogrel Protamine sulfate Vitamin K

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

A client admitted to the hospital with abdominal pain, anemia, and bloody stools reports feeling weak and dizzy. The client has rectal pressure and needs to urinate and move their bowels. The nurse should help them: to the bedside commode. to a standing position so he can urinate. onto the bedpan. to the bathroom.

onto the bedpan. Explanation: A client who's dizzy and anemic is at risk for injury because of his weakened state. Assisting him with the bedpan would best meet his needs at this time without risking his safety. The client may fall if walking to the bathroom, left alone to urinate, or trying to stand up.