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 caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs."

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?

"I will receive parenteral vitamin B12 therapy for the rest of my life."

A client with idiopathic thrombocytopenic purpura (ITP) is admitted to an acute care facility. The nurse monitors the client's platelet count and observes closely for signs and symptoms of bleeding. The client is at greatest risk for cerebral hemorrhage when the platelet count falls below what number?

10,000 rationale The client with ITP is at greatest risk for cerebral hemorrhage when the platelet count falls below 10,000/?l. Although platelet counts of 20,000/?l and 75,000/?l are below normal and increase the client's risk for bleeding, they don't increase the risk as much as a platelet count below 10,000/?l. A platelet count of 135,000/?l is normal and wouldn't occur in a client with ITP.

A health care provider prescribes one tablet of ferrous sulfate daily for a 15-year-old girl who experiences heavy blood flow during her menstrual cycle. The nurse advises the patient and her parent that this over-the-counter preparation must be taken for how many months before stored iron replenishment can occur?

6 to 12 months

A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving:

A-positive blood to an A-negative client rationale: An acute hemolytic reaction occurs when there is an ABO or Rh incompatibility. For example, giving A blood to a B client would cause a hemolytic reaction. Likewise, giving Rh-positive blood to an Rh-negative client would cause a hemolytic reaction. It's safe to give Rh-negative blood to an Rh-positive client if there is a blood type compatibility. O-negative blood is the universal donor and can be given to all other blood types. AB clients can receive either A or B blood as long as there isn't an Rh incompatibility.

A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?

Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels

A patient describes numbness in the arms and hands with a tingling sensation. The patient also frequently stumbles when walking. What vitamin deficiency does the nurse determine may cause some of these symptoms?

B12

Which is a symptom of hemochromatosis?

Bronzing of the skin rationale: Clients with hemochromatosis exhibit symptoms of weakness, lethargy, arthralgia, weight loss, and loss of libido early in the illness trajectory. The skin may appear hyperpigmented from melanin deposits or appear bronze in color.

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?

CBC rationale: 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 male client has been receiving a continuous infusion of weight-based heparin for more than 4 days. The client's PTT is at a level that requires an increase of heparin by 100 units per hour. The client has the laboratory findings shown above. What is the most important action for the nurse to take?

Consult with the physician about discontinuing heparin.

The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?

I have difficulty breathing when walking 30 feet rationale: 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. The client would feel cold and not hot. The client is fatigued and able to sleep often with a decrease in appetite, not an increase.

A home care nurse visits a client diagnosed with atrial fibrillation who is ordered warfarin. The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching?

I'll eat four servings of fresh, dark green vegetables every day

The nurse is performing an assessment for a client with anemia admitted to the hospital to have blood transfusions administered. Why would the nurse need to include a nutritional assessment for this patient?

It may indicate deficiencies in essential nutrients.

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?

Platelet count, prothrombin time, and partial thromboplastin time

A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the health care provider immediately because the client probably is experiencing which problem?

a hemolytic allergic reaction caused by an antigen reaction

Which nursing diagnosis should a nurse expect to see in a care plan for a client in sickle cell crisis?

acute pain related to sickle cell crisis

A client's low prothrombin time (PT) was attributed to low vitamin K levels and the client's PT normalized after administration of vitamin K. When performing discharge education in an effort to prevent recurrence, what should the nurse emphasize?

adequate nutrition

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?

administering and evaluating the effectiveness of opioid analgesics

A client comes to the walk-in clinic complaining of weakness and fatigue. While assessing this client, the nurse finds evidence of petechiae and ecchymoses. The nurse notes that the spleen appears enlarged. What would the nurse suspect is wrong with this client?

aplastic anemia

Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia?

apply prolonged pressure to needle sites or other sources of external bleeding

Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process due to thrombocytopenia in a client with leukemia?

applying prolonged pressure to needle sites or other sources of external 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

The client has been diagnosed with myelodysplastic syndrome with an absolute neutrophil count less than 1000/mm³ and is being admitted to the hospital. The nurse

assigns the client to a private room

A nurse cares for a client with anemia requiring nutritional supplementation. Which nursing intervention best promotes client adherence with the prescribed therapy?

assist the client to incorporate the therapeutic regimen into daily activities

The nurse is planning care for a client with severe fatigue secondary to anemia. What concept will the nurse use as the basis for planning interventions?

assisting in prioritizing activities

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

Which of the following are assessment findings associated with thrombocytopenia? Select all that apply.

bleeding gums epistaxis hematemesis rationale: Pertinent findings of thrombocytopenia include: bleeding gums, epistaxis, hematemesis, hypotension, and tachypnea.

A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply.

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

A client with multiple myeloma reports pain along the spinal column. The client is prescribed naproxen (Aleve) and oxycodone. Prior to administering these medications, the nurse

checks the client's BUN and creatinine

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?

creatinine level of 6 mg/100 mL

What pathophysiological concept related to sickle cell disease predisposes a client with sickle cell disease to pneumonia?

damage to the spleen increases the risk for infection

The nurse cares for a client with iron deficiency anemia. What findings will the nurse expect to find when reviewing the client's CBC results? Select all that apply.

decreased MCV decreased reticulocytes

A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor?

decreased level of erythropoietin

A client has pernicious anemia and has been receiving treatment for several years. Which symptom may be confused with another condition in older adults?

dementia

The nurse is caring for a client with external bleeding. What is the nurse's priority intervention?

direct pressure

You are caring for a 13-year-old diagnosed with sickle cell anemia. The client asks you what they can do to help prevent sickle cell crisis. What would be an appropriate answer to this client?

drink at least 8 glasses of water every day

A client with megaloblastic anemia reports mouth and tongue soreness. What instruction will the nurse give the client regarding eating while managing the client's symptoms?

eat small amounts of bland, soft foods frequently

The nurse is educating a patient with iron deficiency anemia about food sources high in iron and how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance the absorption?

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

A client is prescribed an intravenous dose of iron dextran. What is the nurse's best action?

ensure that epinephrine is available rationale: When iron is given intravenously, the nurse should have emergency medications, such as epinephrine, available in case of anaphylaxis. Iron preparations will not cause a false-positive on stool analysis for occult blood. One dose of iron will not reverse iron-deficiency anemia; in fact, several doses of iron are required to replenish the client's deficient iron stores. The client's hemoglobin levels may increase in a few weeks.

A client has a history of sickle cell anemia with several sickle cell crises over the past 10 years. What blood component results in sickle cell anemia?

hemoglobin S

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?

hemoglobin level rationale: 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.

A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority?

ineffective tissue perfusion: cerebral, cardiopulmonary, GI

The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned the co-worker may have?

iron deficiency anemia

A client admitted to the hospital in preparation for a splenectomy to treat autoimmune hemolytic anemia asks the nurse about the benefits of splenectomy. Which statement best explains the expected effect of splenectomy?

it will remove the major site of RBC destruction rationale: For clients with autoimmune hemolytic anemia, if corticosteroids do not produce remission, a splenectomy (i.e., removal of the spleen) may be performed because it removes the major site of RBC destruction.

During the review of morning laboratory values for a client reporting severe fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron deficiency anemia based on which finding?

low ferritin level concentration

A client with sickle cell anemia has a

low hematocrit rationale: A client with sickle cell anemia has a low hematocrit and sickled cells on the smear. A client with sickle cell trait usually has a normal hemoglobin level, a normal hematocrit, and a normal blood smear.

The nurse monitors the laboratory data for several clients who are diagnosed with hypoproliferative anemias.

microlytic anemia - decreased MCV - decreased reticulocytes megaloblastic anemia - increased mCV - increased TIBC - decreased vitamin B12 - decreased folate rationale: There are three basic types of anemia: hypoproliferative, bleeding, and hemolytic. Each type of anemia presents differently in regard to laboratory data that is expected. The client who is diagnosed with microcytic anemia will have the following laboratory data: decreased mean corpuscular volume (MCV), decreased reticulocytes, and decreased total iron-binding capacity (TIBC). The client who is diagnosed with a megaloblastic anemia (e.g., vitamin B12 and folate deficiencies) will have the following laboratory data: increased MCV and decreases in either serum vitamin B12 or folate levels. Microcytic anemias do not present with the following laboratory data: increased MCV and deficiencies in both vitamin B12 and folate levels. Megaloblastic anemias do not present with the following laboratory data: decreased MCV, decreased reticulocytes, and increased TBIC.

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?

neurologic involvement

A nurse suspects that a patient may have aplastic anemia based on clinical manifestations and assessment. Which one of the following lab results would be consistent with this diagnosis?

neutrophil count of 50% rationale: Laboratory values consistent with a diagnosis of aplastic anemia would be a hemoglobin less than 9 g/dL, significant neutropenia and thrombocytopenia, and a reduced erythrocyte count.

The nurse, caring for a client in the emergency room with a severe nosebleed, becomes concerned when the client asks for a bedpan. The nurse documents the stool as loose, tarry, and black looking. The nurse suspects the client may have thrombocytopenia. What should be the nurse's priority action?

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

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?

observe the client's stools for blood

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?

obtain the pain medication and delay the bath and position change until the medication reaches its peak rationale: 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.

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:

onto the bedpan

A nurse is caring for a client with iron deficiency anemia. Which food or beverage will the nurse suggest to the client to eat or drink when taking supplemental iron?

orange juice

A client diagnosed with systemic lupus erythematosus comes to the emergency department with severe back pain. The client is taking prednisone daily and reported feeling pain after manually opening the garage door. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain?

osteoporosis

A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?

pallor, tachycardia, and a sore tongue

Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets?

pancytopenia

A patient had gastric bypass surgery 3 years ago and now, experiencing fatigue, visits the clinic to determine the cause. The patient takes pantoprazole for the treatment of frequent heartburn. What type of anemia is this patient at risk for?

pernicious anemia

A client awaiting a bone marrow aspiration asks the nurse to explain where on the body the procedure will take place. What body part does the nurse identify for the client?

posterior iliac crest rationale: In adults, bone marrow is usually aspirated from the posterior iliac crest and rarely from the sternum. Bone marrow is not aspirated from the femur or ankle.

Which of the following is considered an antidote to heparin?

protamine sulfate

A pregnant woman is hospitalized as the result of sickle-cell crisis. Which finding indicates the outcome has been achieved for this client?

reports joint pain less than 3 on a scale of 0 to 10

A client at the clinic has just been diagnosed with iron deficiency anemia. What would you recommend the client consume to promote the absorption of iron?

rich sources of vitamin C

A client is prescribed 325 mg/day of oral ferrous sulfate. What does the nurse include in client teaching?

take 1 hour before breakfast

A client with chronic anemia has received multiple transfusions. Which client action would the nurse be concerned about relative to the client's condition?

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

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 strong correlation between iron stores and hemoglobin levels rationale: 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?

thrombocytopenia

A nurse is caring for a client with thalassemia who is being transfused. What is the nurse's role during a transfusion?

to closely monitor the rate of administration rationale: In a client with thalassemia, when transfusions are necessary, the nurse closely monitors the rate of administration. Assessing for enlargement and tenderness over the liver and spleen, advising rest, or administering vitamin B12 injections are not indicated for thalassemia.

A nurse is doing a physical examination of a child with sickle cell anemia. When the child asks why the nurse auscultates the lungs and heart, what would be best the response by the nurse?

to detect the abnormal sounds suggestive of acute chest syndrome and heart failure

The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. What is the rationale for this statement by the nurse?

trauma and microabrasions from a non-electric razor may contribute to anemia rationale: In a client with leukemia who is at risk for hemorrhage, the nurse handles the client gently when assisting and encourages the client to use electric razors. Trauma and microabrasions from razors may contribute to anemia from bleeding. Fragile tissues and altered clotting mechanisms may result in hemorrhage even after minor trauma. Therefore, the nurse inspects the skin for signs of bruising and petechiae and reports melena, hematuria, or epistaxis (nosebleeds). The risks for spontaneous and uncontrolled bleeding or infection from microorganisms are not addressed by the use of electric razors.

When evaluating a patient's symptoms that are consistent with a diagnosis of leukemia, the nurse is aware that all leukemias have which common feature?

unregulated accumulation of white cells in the bone marrow, which replace normal marrow elements

The nurse should advise a client with iron deficiency anemia to take which action in order to prevent staining of the teeth?

use a straw or place a spoon at the back of the mouth to take the liquid supplement rationale: For a client with iron deficiency anemia who is taking an oral iron supplement, the nurse instructs the client to use a straw or place a spoon at the back of the mouth to take the liquid supplement to avoid staining the teeth. The nurse advises the client to take iron with or immediately after meals to avoid gastric distress. The client is advised to avoid having iron simultaneously with an antacid, as the antacid will interfere with iron absorption.

A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?

use the smallest needle possible for injections rationale: Because thrombocytopenia alters coagulation, it poses a high risk of bleeding. To help prevent capillary bleeding, the nurse should use the smallest needle possible when administering injections. The nurse doesn't need to limit visits by family members because they don't pose any danger to the client. The nurse should provide comfort measures and maintain the client on bed rest; activities such as using a wheelchair can cause bleeding. The nurse records fluid intake and output to monitor hydration; however, this action doesn't protect the client from a complication of thrombocytopenia.

During preparation for bowel surgery, a client receives an antibiotic to reduce intestinal bacteria. The nurse knows that hypoprothrombinemia may occur as a result of antibiotic therapy interfering with synthesis of which vitamin?

vitamin K

Which medication is the antidote to warfarin?

vitamin K

A young client is diagnosed with a mild form of hemophilia and is experiencing bleeding in the joints with pain. In preparing the client for discharge, what instructions should the nurse provide?

wear a medical identification bracelet

A nurse cares for clients with hematological disorders and notes that women are diagnosed with hemochromatosis at a much lower rate than men. What is the primary reason for this?

women lose iron through menstrual cycles