Chapter 31: Caring for Clients with Disorders of the Hematopoietic System

A client has a history of seizures and presents with severe fatigue, frequent headaches, and a sore, beefy-red tongue. What could be causing the client's current condition? Select all that apply. a. alcoholism b. intestinal disorders c. lack of meat consumption d. lack of vitamin B

a, b Older adults and clients with alcoholism, intestinal disorders that affect food absorption, malignant disorders, and chronic illnesses often have a folic acid deficiency because of poor nutrition.

Which of the following are assessment findings associated with thrombocytopenia? Select all that apply. a. Bleeding gums b. Epistaxis c. Hematemesis d. Bradypnea e. Hypertension

a,b,c Pertinent findings of thrombocytopenia include: bleeding gums, epistaxis, hematemesis, hypotension, and tachypnea.

A client with acute kidney injury has decreased erythropoietin production. Upon analysis of the client's complete blood count, the nurse will expect which of the following results? a. An increased hemoglobin and decreased hematocrit b. A decreased hemoglobin and hematocrit c. A decreased mean corpuscular volume (MCV) and red cell distribution width (RDW) d. An increased mean corpuscular volume (MCV) and red cell distribution width (RDW)

a The decreased production of erythropoietin will result in a decreased hemoglobin and hematocrit. The client will have normal MCV and RDW because the erythrocytes are normal in appearance.

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

b 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.

Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called a. blast cells. b. megaloblasts. c. mast cells. d. monocytes.

b Megaloblasts are abnormally large erythrocytes. Blast cells are primitive white blood cells (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.

The nurse is caring for a client with external bleeding. What is the nurse's priority intervention? a. Elevation of the extremity b. Pressure point control c. Direct pressure d. Application of a tourniquet

c Applying direct pressure to an injury is the initial step in controlling bleeding. Elevation reduces the force of flow, but direct pressure is the first step. The nurse may use pressure point control for severe or arterial bleeding. Pressure points (those areas where large blood vessels can be compressed against bone) include femoral, brachial, facial, carotid, and temporal artery sites. The nurse should avoid applying a tourniquet unless all other measures have failed, because it may further damage the injured extremity.

A client with several chronic health problems has been newly diagnosed with a qualitative platelet defect. What component of the client's previous medication regimen may have contributed to the development of this disorder? a. Calcium carbonate b. Vitamin B12 c. Aspirin d. Vitamin D

c Aspirin may induce a platelet disorder. Even small amounts of aspirin reduce normal platelet aggregation, and the prolonged bleeding time lasts for several days after aspirin ingestion. Calcium, vitamin D, and vitamin B12 do not have the potential to induce a platelet defect.

A client with a pulmonary embolism is being treated with a heparin infusion. What diagnostic finding suggests to the nurse that treatment is effective? a. The client's PT is within reference ranges. b. Arterial blood sampling tests positive for the presence of factor XIII. c. The client's platelet level is below 100,000/mm3. d. The client's activated partial thromboplastin time (aPTT) is 1.5 to 2.5 times the control value.

d The therapeutic effect of heparin is monitored by serial measurements of the aPTT; the dose is adjusted to maintain the range at 1.5 to 2.5 times the laboratory control. Heparin dosing is not determined on the basis of platelet levels, the presence or absence of clotting factors, or PT levels.

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? a. Compensatory polycythemia stimulated by thrombocytopenia b. Unregulated accumulation of white cells in the bone marrow, which replace normal marrow elements c. Increased blood viscosity, resulting from an overproduction of white cells d. Reduced plasma volume in response to a reduced production of cellular elements

b The term leukemia means "white blood," which is used to describe the neoplastic proliferation of one hematopoietic cell type (granulocytes, monocytes, lymphocytes, and sometimes, erythrocytes and megakaryocytes).

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? a. Milk b. Orange juice c. Leafy green vegetables d. Kidney beans

b Vitamin C found in orange juice improves the absorption of iron. The other answer choices are not the best for improving absorption of iron.

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? a. Beans, dried fruits, and leafy, green vegetables b. Fruits high in vitamin C, such as oranges and grapefruits c. Berries and orange vegetables d. Dairy products

a 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.

Which of the following describes a red blood cell (RBC) that has pale or lighter cellular contents? a. Hypochromic b. Normocytic c. Microcytic d. Hyperchromic

a An RBC that has pale or lighter cellular contents is hypochromic. A normocytic RBC is normal or average in size. A microcytic RBC is smaller than normal. Hyperchromic is used to describe an RBC that has darker cellular contents.

A client has pernicious anemia and has been receiving treatment for several years. Which symptom may be confused with another condition in older adults? a. dementia b. stomatitis c. glossitis d. ataxia

a Pernicious anemia may be accompanied by a dementia with symptoms similar to Alzheimer's disease. Therefore, clients experiencing cognitive changes should be screened because early detection of pernicious anemia is critical to prevent neurologic damage.

The results of a client's most recent blood work and physical assessment are suggestive of immune thrombocytopenic purpura (ITP). This client should undergo testing for which of the following potential causes? Select all that apply. a. Hepatitis b. Acute kidney injury c. HIV d. Malignant melanoma e. Cholecystitis

a, b Viral illnesses have the potential to cause ITP. Acute kidney injury, malignancies, and gallbladder inflammation are not typical causes of ITP.

A patient, newly diagnosed with thrombocytopenia, is admitted to the medical unit. After the admission assessment the patient asks the nurse to explain the disease. What should the nurse explain to the patient about this condition? a. There could be an attack on the platelets by the antibodies b. There could be decreased production of platelets c. There could be elevated platelet production. d. There could be decreased white blood cell production.

b Thrombocytopenia can result from a decreased platelet production, increased platelet destruction, or increased consumption of platelets. Increased production of platelets is associated with thrombocythemia. Decreased white blood cell production is associated with leukopenia.

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? a. Anemia b. Leukopenia c. Thrombocytopenia d. Neutropenia

c 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.

The nurse on the pediatric unit is caring for a 10-year-old boy with a diagnosis of hemophilia. The nurse should assess carefully for indication of what nursing diagnosis? a. Hypothermia b. Diarrhea c. Ineffective coping d. Imbalanced nutrition: Less than body requirements

c Most clients with hemophilia are diagnosed as children. They often require assistance in coping with the condition because it is chronic, places restrictions on their lives, and is an inherited disorder that can be passed to future generations. Children with hemophilia are not at risk of hypothermia, diarrhea, or imbalanced nutrition.

A client with a history of atrial fibrillation has contacted the clinic saying that she has accidentally overdosed on her prescribed warfarin. The nurse should recognize the possible need for what antidote? a. IVIG b. Factor X c. Vitamin K d. Factor VIII

c Vitamin K is given as an antidote for warfarin toxicity.

The nurse is planning the care of a client with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this client's health problem is due to what? a. Production of inadequate quantities of RBCs b. Premature release of immature RBCs c. Injury to the RBCs in circulation d. Abnormalities in the structure and function of RBCs

d Vitamin B12 and folate deficiencies are characterized by the production of abnormally large erythrocytes called megaloblasts. Because these cells are abnormal, many are sequestered (trapped) while still in the bone marrow, and their rate of release is decreased. Some of these cells actually die in the marrow before they can be released into the circulation. This results in megaloblastic anemia. This pathologic process does not involve inadequate production, premature release, or injury to existing RBCs.

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? a. B12 b. C c. A d. Folate

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

A client lives with a diagnosis of sickle cell disease and receives frequent blood transfusions. The nurse should recognize the client's consequent risk of what complication of treatment? a. Hypovolemia b. Vitamin B12 deficiency c. Thrombocytopenia d. Iron overload

d Clients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. These individuals are not at risk for hypovolemia and there is no consequent risk for low platelet or vitamin B12 levels.

A nurse is planning the care of a client who has a diagnosis of hemophilia A. When addressing the nursing diagnosis of Acute Pain Related to Joint Hemorrhage, what principle should guide the nurse's choice of interventions? a. Gabapentin (Neurontin) is effective because of the neuropathic nature of the client's pain. b. Opioids partially inhibit the client's synthesis of clotting factors. c. Opioids may cause vasodilation and exacerbate bleeding. d. NSAIDs are contraindicated due to the risk for bleeding.

d NSAIDs may be contraindicated in clients with hemophilia due to the associated risk of bleeding. Opioids do not have a similar effect and they do not inhibit platelet synthesis. The pain associated with hemophilia is not neuropathic.

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? a. CBC b. antibiotic c. chest radiograph d. ECG

a 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.

An client has pernicious anemia and has been receiving treatment for several years. What is the client lacking that results in pernicious anemia? a. intrinsic factor b. vitamin B c. extrinsic factor d. hemoglobin

a Pernicious anemia develops when a client lacks intrinsic factor, which normally is present in stomach secretions. Intrinsic factor is necessary for absorption of vitamin B12. Vitamin B12, the extrinsic factor in blood, is required for the maturation of erythrocytes.

A client has been diagnosed with pernicious anemia. During client education, the nurse emphasizes the importance of lifelong intramuscular administration of: a. vitamin B12. b. vitamin A. c. vitamin C. d. folic acid.

a For a client with pernicious anemia, the nurse emphasizes the importance of lifelong administration of vitamin B12. He or she teaches the client or a family member of the proper method to administer vitamin B12 injections.

A nurse on a hematology/oncology floor is caring for a client with aplastic anemia. Which would not be included in the client's discharge instructions? a. Use a disposable razor when shaving. b. Avoid contact with family/friends who are sick. c. Encourage frequent handwashing. d. Plan for frequent periods of rest.

a People with aplastic anemia usually have insufficient erythrocytes, leukocytes, and platelets. Encourage behaviors that will lower the risk for bleeding. Avoiding contact with people who are sick reduces the risk of acquiring an infection. Handwashing reduces the risk of acquiring an infection. Anemia can cause fatigue and shortness of breath with even mild exertion.

A thin client is prescribed iron dextran intramuscularly. What is most important action taken by the nurse when administering this medication? a. Employs the Z-track technique b. Uses a 23-gauge needle c. Injects into the deltoid muscle d. Rubs the site vigorously

a 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 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? a. Women lose iron through menstrual cycles b. Women rarely manifest the gene expression c. Women have lower hemoglobin levels d. Women require grater folic acid supplementation

a Hemochromatosis is a genetic condition where excess iron is absorbed in the GI tract and deposited in various organs, making them dysfunctional. Women are often less affected than men because women lose excess iron through their menstrual cycles. The other answer choices are not correct reasons why women are impacted less than men with hemochromatosis.

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? a. Limiting the client's intake of oral and IV fluids b. Administering and evaluating the effectiveness of opioid analgesics c. Encouraging the client to ambulate immediately d. Limit foods that contain folic acid

b 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 .

A client newly diagnosed with thrombocytopenia is admitted to the medical unit. After the admission assessment, the client asks the nurse to explain the disease. What potential etiology should the nurse explain to this client? a. An attack on the platelets by antibodies b. Decreased production of platelets. c. Impaired communication between platelets. d. An autoimmune process causing platelet malfunction.

b Thrombocytopenia can result from a decreased platelet production, increased platelet destruction, or increased consumption of platelets. Impaired platelet communication, antibodies, and autoimmune processes are not typical pathologies.

A client is being treated on the medical unit for a sickle cell crisis. The nurse's most recent assessment reveals a fever and a new onset of fine crackles on lung auscultation. What is the nurse's most appropriate action? a. Apply supplementary oxygen by nasal cannula. b. Administer bronchodilators by nebulizer. c. Liaise with the respiratory therapist and consider high-flow oxygen. d. Inform the health care provider that the client may have an infection.

d Clients with sickle cell disease are highly susceptible to infection, thus any early signs of infection should be reported promptly. There is no evidence of respiratory distress, so oxygen therapy and bronchodilators are not indicated.

A nurse cares for a client suspected of having iron deficient anemia. Which diagnostic test will the nurse expect the health care provider to order in order to definitively diagnose the condition? a. Blood smear b. Bone marrow aspiration c. Serum ferritin d. Complete blood count

b The definitive method of diagnosis for iron deficiency anemia is bone marrow aspiration. The other answer choices may also be used to help with the diagnosis of the condition; however, these are not definitive diagnostic tests.

A 63-year-old woman has been diagnosed with polycythemia vera (PV) after undergoing a series of diagnostic tests. When the woman's nurse is providing health education, what subject should the nurse prioritize? a. Maintenance of long-term vascular access device b. Nutritional modifications necessary for maintaining a low-iron diet c. Strategies for managing activity d. Lifestyle modifications and techniques for preventing thromboembolism

d The increased blood volume and viscosity that are the hallmarks of PV create a significant risk of thromboembolism. A vascular access device is not necessary for the treatment of PV, and a low-iron diet does not resolve the disease. Patients may experience fatigue, but this risk is superseded by that of thromboembolism.

Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets? a. Pancytopenia b. Anemia c. Leukopenia d. Thrombocytopenia

a Pancytopenia is defined as an abnormal decrease in WBCs, RBCs, and platelets. The condition may be congenital or acquired. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of WBCs in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.

Which is a symptom of hemochromatosis? a. Bronzing of the skin b. Inflammation of the mouth c. Inflammation of the tongue d. Weight gain

a 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.

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

c 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 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? a. Thiamine b. Folate c. B12 d. Iron

c The hematologic effects of vitamin B12 deficiency are accompanied by effects on other organ systems, particularly the gastrointestinal tract and nervous system. Patients with pernicious anemia may become confused; more often, they have paresthesias in the extremities (particularly numbness and tingling in the feet and lower legs). They may have difficulty maintaining their balance because of damage to the spinal cord, and they also lose position sense (proprioception).

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? a. Potassium level b. Creatinine level c. Hemoglobin level d. Folate levels

c 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 being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met? a. Assess for edema. b. Assess skin integrity frequently. c. Assess the client's level of consciousness frequently. d. Closely monitor intake and output.

d The client with DIC is at a high risk of deficient fluid volume. The nurse can best gauge the effectiveness of care by closely monitoring the client's intake and output. Each of the other assessments is a necessary element of care, but none addresses fluid balance as directly as close monitoring of intake and output.

A nurse cares for a client with anemia requiring nutritional supplementation. Which nursing intervention best promotes client adherence with the prescribed therapy? a. Assist the client to incorporate the therapeutic regimen into daily activities. b. Develop a therapeutic regimen recommendation for the client. c. Assist the client to use a medication reminder system for the therapeutic regimen. d. Develop a therapeutic regimen based on the client's understanding of the medication.

a The best way for the nurse to promote adherence to the therapeutic regimen is to assist the client to incorporate the therapeutic regimen into daily activities. This action is the only answer choice that is a collaborative effort with the client and is the reason it is correct.

A client with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to prescribe for this client? a. Packed red blood cells (PRBCs) b. Vitamin K c. Oral anticoagulants d. Heparin infusion

a Clients with liver dysfunction may have life-threatening hemorrhage from peptic ulcers or esophageal varices. In these cases, replacement with fresh-frozen plasma, PRBCs, and platelets is usually required. Vitamin K may be prescribed once the bleeding is stopped, but that is not what is needed to stop the bleeding of the varices. Anticoagulants would exacerbate the client's bleeding.

The nurse should advise a client with iron deficiency anemia to take which action in order to prevent staining of the teeth? a. Take iron with or immediately after meals b. Dilute liquid preparations of iron with juice and drink with a straw c. Avoid taking iron simultaneously with an antacid d. Do not combine iron with other prescribed or over-the-counter medications

b For a client with iron deficiency anemia who is taking an oral iron supplement, the nurse instructs the client to dilute liquid preparations of iron with another liquid, such as juice, and drink with a straw 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 taking iron simultaneously with an antacid, as the antacid will interfere with iron absorption.

After teaching a client about taking daily oral iron preparations for a moderate iron deficiency anemia, which statement by the client indicates to the nurse that additional instruction is needed? a. "I will occasionally take a stool softener if I feel constipated." b. "I will call the doctor if my stools turn black." c. "I will increase my fluid and fiber intake while I am taking the iron tablets." d. "I will take the iron with orange juice about an hour before eating."

b Iron replacement therapy may change the color of stool, usually to dark green or black. Iron is best absorbed on an empty stomach, so the client is instructed to take the supplement an hour before meals. Many clients have difficulty tolerating iron supplements because of gastrointestinal (GI) side effects (primarily constipation). Limit GI side effects by adding a stool softener or increasing dietary fiber and fluids. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron.

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? a. Obtaining assistance from someone to help with cleaning in the home. b. Requesting a leave of absence from her job. c. Prioritizing and balancing activities and rest. d. Finding a babysitter to take care of her children.

c 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 nursing intervention should be incorporated into the plan of care to manage the delayed clotting process due to thrombocytopenia in a client with leukemia? a. Implementing neutropenic precautions b. Eliminating direct contact with others who are infectious c. Applying prolonged pressure to needle sites or other sources of external bleeding d. Monitoring temperature at least once per shift

c The interventions for a client with thrombocytopenia are the same as those for a client with cancer who is at risk for bleeding. 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 has been living with a diagnosis of anemia for several years and has experienced recent declines in her hemoglobin levels despite active treatment. What assessment finding would signal complications of anemia? a. Venous ulcers and visual disturbances b. Fever and signs of hyperkalemia c. Epistaxis and gastroesophageal reflux d. Shortness of breath and peripheral edema

d A significant complication of anemia is heart failure from chronic diminished blood volume and the heart's compensatory effort to increase cardiac output. Clients with anemia should be assessed for signs and symptoms of heart failure, including dyspnea and peripheral edema. None of the other listed signs and symptoms is characteristic of heart failure.

A critical care nurse is caring for a client with immune hemolytic anemia. The client is not responding to conservative treatments, and his condition is now becoming life-threatening. The nurse is aware that a treatment option in this case may include what? a. Hepatectomy b. Vitamin K administration c. Platelet transfusion d. Splenectomy

d A splenectomy may be the course of treatment if autoimmune hemolytic anemia does not respond to conservative treatment. Vitamin K administration is treatment for vitamin K deficiency and does not resolve anemia. Platelet transfusion may be the course of treatment for some bleeding disorders. Hepatectomy would not help the patient.

When a nurse is planning discharge teaching for a client admitted with sickle cell crisis, which information should the nurse include in the teaching? a. Drink only one caffeinated beverage daily b. Take a daily multivitamin with iron c. Limit fluids to 2 quarts a day d. Receive pneumococcal and annual influenza vaccinations

d Clients with sickle cell anemia must treat infections promptly with appropriate antibiotics; infections, particularly pneumococcal infections, can be serious. These clients should receive pneumococcal and annual influenza vaccinations.

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? a. Potassium level of 5.2 mEq/L b. Magnesium level of 2.5 mg/dL c. Calcium level of 9.4 mg/dL d. Creatinine level of 6 mg/100 mL

d 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.

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? a. Eating calf's liver with a glass of orange juice b. Eating leafy green vegetables with a glass of water c. Eating apple slices with carrots d. Eating a steak with mushrooms

a 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 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? a. hemoglobin S b. hemoglobin F c. hemoglobin A d. hemoglobin M

a Hemoglobin A (HbA) normally replaces fetal hemoglobin (HbF) about 6 months after birth. In people with sickle cell anemia, however, an abnormal form of hemoglobin, hemoglobin S (HbS), replaces HbF. HbS causes RBCs to assume a sickled shape under hypoxic conditions.

The nurse's brief review of a client's electronic health record indicates that the client regularly undergoes therapeutic phlebotomy. Which of the following rationales for this procedure is most plausible? a. The client may chronically produce excess red blood cells. b. The client may frequently experience a low relative plasma volume. c. The client may have impaired stem cell function. d. The client may previously have undergone bone marrow biopsy.

a Persistently elevated hematocrit is an indication for therapeutic phlebotomy. It is not used to address excess or deficient plasma volume and is not related to stem cell function. Bone marrow biopsy is not an indication for therapeutic phlebotomy.

A client with sickle cell anemia has a a. low hematocrit. b. high hematocrit. c. normal hematocrit. d. normal blood smear.

a 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 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? a. Iron deficiency anemia b. Megaloblastic anemia c. Sickle cell anemia d. Aplastic anemia

a People with iron deficiency anemia may crave ice, starch, or dirt; this craving is known as pica.

The nurse is currently planning the care of a patient with multiple myeloma who is experiencing bone destruction. When reviewing the patient's most recent blood work, what value would the nurse pay particular attention to? a. Hypercalcemia b. Hyperproteinemia c. Elevated serum viscosity d. Elevated red blood cell (RBC) count

a Hypercalcemia may occur when bone destruction occurs due to the disease process. Elevated serum viscosity occurs because plasma cells excrete excess immunoglobulin. RBC count will be decreased. Hyperproteinemia would not be present.

The nurse is providing palliative care for a 69-year-old patient who has a diagnosis of multiple myeloma. The patient states that she enjoyed good health for most of her life and rarely had to visit her family health care provider until she experienced the first signs and symptoms of her current illness. Which of the following complaints most likely prompted the patient to initially seek care? a. Lymphadenopathy b. Bone pain c. Recurrent infections d. Fatigue and activity intolerance

b As many as 90% of patients with multiple myeloma develop bone lesions. Although patients can have asymptomatic bone involvement, the most common presenting symptom of multiple myeloma is bone pain, usually in the back or ribs. Lymphadenopathy, infections, and fatigue are not among the most common initial complaints associated with multiple myeloma.

A pregnant woman is hospitalized as the result of sickle-cell crisis. Which finding indicates the outcome has been achieved for this client? a. Reports joint pain less than 3 on a scale of 0 to 10 b. Takes hydroxyurea during her pregnancy c. Exhibits a temperature more than 100.3°F d. Describes the importance of staying cool

a An expected outcome for a client experiencing a sickle-cell crisis is control and reduction of pain. Hydroxyurea is contraindicated in pregnancy because of the risk it poses for congenital abnormalities. An indication that the client is free from infection is exhibiting a normal temperature; 100.3°F is an elevated temperature. To minimize crises, the client needs to stay warm not cool.

A patient with a diagnosis of immune thrombocytopenic purpura (ITP) is currently receiving IVIG for the treatment of her health condition. The nurse who is providing this patient's care is aware that ITP is a consequence of: a. Inappropriate platelet aggregation on the walls of the great vessels b. Impaired liver function and the sequestering of platelets by hepatocytes c. Hemolysis of platelets in individuals who lack immunity to the Epstein-Barr virus d. Platelet destruction and impaired platelet production resulting from an autoimmune process

d Although the precise cause of ITP remains unknown, the platelet count is decreased by a combination of autoantibody-mediated platelet destruction and impaired platelet production secondary to autoantibody effects on the megakaryocyte. Viruses, impaired liver function, and inappropriate platelet aggregation are not dimensions of the etiology of ITP.

When teaching a client with sickle cell disease about strategies to prevent crises, what measures should the nurse recommend? a. Using prophylactic antibiotics and performing meticulous hygiene b. Maximizing physical activity and taking OTC iron supplements c. Limiting psychosocial stress and eating a high-protein diet d. Avoiding cold temperatures and ensuring sufficient hydration

d Keeping warm and providing adequate hydration can be effective in diminishing the occurrence and severity of attacks. Hygiene, antibiotics, and high protein intake do not prevent crises. Maximizing activity may exacerbate pain and be unrealistic.

The most common cause of iron deficiency anemia in men and postmenopausal women is a. menorrhagia. b. iron malabsorption. c. bleeding. e. chronic alcoholism.

c The most common cause of iron deficiency anemia in men and postmenopausal women is bleeding from ulcers, gastritis, inflammatory bowel disease, or gastrointestinal (GI) tumors. Menorrhagia is the most common cause in premenopausal women. Iron malabsorption is another cause, which is seen in clients with celiac disease. Clients with chronic alcoholism often have chronic blood loss from the GI tract.

The nurse is assessing a patient who comes to the clinic and reports feeling constantly tired and very weak. The patient also has a very sore tongue, and upon observing the patient's oral cavity, the nurse notices the tongue is beefy red. What type of anemia does the nurse know these symptoms indicate? a. Iron deficiency anemia b. Megaloblastic anemia c. Sickle cell anemia d. Aplastic anemia

b Weakness, fatigue, and general malaise are common in anemia, as are pallor of the skin and mucous membranes (conjunctivae, oral mucosa) (Fig. 33-1). Jaundice may be present in patients with megaloblastic anemia or hemolytic anemia. The tongue may be smooth and red (in iron deficiency anemia) or beefy red and sore (in megaloblastic anemia).

The nurse is preparing the patient for a test to determine the cause of vitamin B12 deficiency. The patient will receive a small oral dose of radioactive vitamin B12 followed by a large parenteral dose of nonradioactive vitamin B12. What test is the patient being prepared for? a. Bone marrow aspiration b. Schilling test c. Bone marrow biopsy d. Magnetic resonance imaging (MRI) study

b The classic method of determining the cause of vitamin B12 deficiency is the Schilling test, in which the patient receives a small oral dose of radioactive vitamin B12, followed in a few hours by a large, nonradioactive parenteral dose of vitamin B12 (this aids in renal excretion of the radioactive dose).

The nurse is assessing a client who lives in a community that is at a very high altitude. When reviewing the client's most recent laboratory values, the nurse notes that the client has elevated red blood cell levels. The client denies having any unwanted symptoms. What is the nurse's best response? a. Document the assessment finding. b. Promptly inform the primary care provider. c. Perform a focused cardiovascular assessment. d. Monitor vital signs every 4 hours.

a For people who live at high altitudes, erythrocytosis is a normal phenomenon and usually requires no treatment. Further referrals or assessments are likely unnecessary.

A client's absolute neutrophil count (ANC) is 440/mm3 but the nurse's assessment reveals no apparent signs or symptoms of infection. What action should the nurse prioritize when providing care for this client? a. Meticulous hand hygiene b. Timely administration of antibiotics c. Provision of a nutrient-dense diet d. Maintaining a sterile care environment

a Providing care for a client with neutropenia requires that the nurse adhere closely to standard precautions and infection control procedures. Hand hygiene is central to such efforts. Prophylactic antibiotics are rarely used and it is not possible to provide a sterile environment for care. Nutrition is highly beneficial, but hand hygiene is the central aspect of care.

A nurse cares for a client with a hematological disorder and malnutrition. What is the nurse's best understanding of how the client's nutritional status may worsen the client's hematological condition? a. Decreased protein stores lead to decreased immune response b. Decreased fat stores lead to decreased ability for red blood cells c. Decreased calories lead to decreased immune response d. Decreased carbohydrates lead to decreased oxygen affinity of the hemoglobin

a Decreased protein stores lead to a decreased immune response and worsening of the client's hematological condition. Decreased intake of carbohydrates, calories, or fat stores are not the primary sources for worsening of the client's condition.

A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? a. Pallor, bradycardia, and reduced pulse pressure b. Pallor, tachycardia, and a sore tongue c. Sore tongue, dyspnea, and weight gain d. Angina pectoris, double vision, and anorexia

b Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina pectoris; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia.

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy? a. "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear." b. "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal." c. "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year." d. "I will receive parenteral vitamin B12 therapy for the rest of my life."

d Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life.

An adult client has been diagnosed with iron-deficiency anemia. What nursing diagnosis is most likely to apply to this client's health status? a. Risk for deficient fluid volume related to impaired erythropoiesis b. Risk for infection related to tissue hypoxia c. Acute pain related to uncontrolled hemolysis d. Fatigue related to decreased oxygen-carrying capacity

d Fatigue is the major assessment finding common to all forms of anemia. Anemia does not normally result in acute pain or fluid deficit. The client may have an increased risk of infection due to impaired immune function, but fatigue is more likely.

A client with a recent diagnosis of ITP has asked the nurse why the care team has not chosen to administer platelets, stating, "I have low platelets, so why not give me a transfusion of exactly what I'm missing?" How should the nurse best respond? a. "Transfused platelets usually aren't beneficial because they're rapidly destroyed in the body." b. "A platelet transfusion often blunts your body's own production of platelets even further." c. "Finding a matching donor for a platelet transfusion is exceedingly difficult." d. "A very small percentage of the platelets in a transfusion are actually functional."

a Despite extremely low platelet counts, platelet transfusions are usually avoided. Transfusions tend to be ineffective not because the platelets are nonfunctional but because the client's antiplatelet antibodies bind with the transfused platelets, causing them to be destroyed. Matching the client's blood type is not usually necessary for a platelet transfusion. Platelet transfusions do not exacerbate low platelet production.

A patient is taking prednisone 60 mg per day for the treatment of an acute exacerbation of Crohn's disease. The patient has developed lymphopenia with a lymphocyte count of less than 1,500 mm3. What should the nurse monitor the client for? a. The onset of a bacterial infection b. Bleeding c. Abdominal pain d. Diarrhea

a Lymphopenia (a lymphocyte count less than 1,500/mm3) can result from ionizing radiation, long-term use of corticosteroids, uremia, infections (particularly viral infections), some neoplasms (e.g., breast and lung cancers, advanced Hodgkin disease), and some protein-losing enteropathies (in which the lymphocytes within the intestines are lost) (Kipps, 2010). When lymphopenia is mild, it is often without sequelae; when severe, it can result in bacterial infections (due to low B lymphocytes) or in opportunistic infections (due to low T lymphocytes).

A client with von Willebrand disease (vWD) has experienced recent changes in bowel function that suggest the need for a screening colonoscopy. What intervention should be performed in anticipation of this procedure? a. The client should not undergo the normal bowel cleansing protocol prior to the procedure. b. The client should receive a unit of fresh-frozen plasma 48 hours before the procedure. c. The client should be admitted to the surgical unit on the day before the procedure. d. The client should be given necessary clotting factors before the procedure.

d A goal of treating vWD is to replace the deficient protein (e.g., vWF or factor VIII) prior to an invasive procedure to prevent subsequent bleeding. Bowel cleansing is not contraindicated and FFP does not reduce the client's risk of bleeding. There may or may not be a need for preprocedure hospital admission.

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? a. It will remove the major site of red blood cell (RBC) destruction. b. It will reduce the destruction of platelets by macrophages. c. It will increase production of platelets by the bone marrow. d. It will increase red blood cell (RBC) production to compensate for blood loss.

a 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.

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? a. Take ibuprofen for joint pain. b. Take warm baths to lessen pain. c. Wear a medical identification bracelet. d. Undergo genetic testing and counseling if the client is male.

c Clients with hemophilia should wear a medical identification bracelet about having this disease. Ibuprofen interferes with platelet aggregation and may increase the client's bleeding. A warm bath may lessen pain but increase bleeding. Genetic testing and counseling are not necessary for male clients, because females are the carriers of the genetic material for hemophilia.

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? a. Activity intolerance b. Impaired tissue integrity c. Impaired oral mucous membranes d. Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI

d These are all appropriate nursing diagnoses for the client with thrombocytopenia. However, the risk of cerebral and GI hemorrhage and hypotension pose the greatest risk to the physiological integrity of the client.

The nurse cares for several clients with hematological conditions. Which assessment needs will the nurse prioritize for the client with aplastic anemia? Select all that apply. a. Infection b. Bleeding c. Injury d. Oxygenation e. Perfusion

a, b All clients with aplastic anemia need to have prioritized assessments for infection and bleeding. Injury, oxygenation, and perfusion are not the priority assessments for clients with aplastic anemia.

A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia? a. Nights sweats, weight loss, and diarrhea b. Dyspnea, tachycardia, and pallor c. Nausea, vomiting, and anorexia d. Itching, rash, and jaundice

b Signs of iron deficiency anemia include dyspnea, tachycardia, and pallor, as well as fatigue, listlessness, irritability, and headache. Night sweats, weight loss, and diarrhea may signal acquired immunodeficiency syndrome. Nausea, vomiting, and anorexia may be signs of hepatitis B. Itching, rash, and jaundice may result from an allergic or hemolytic reaction.

A nurse cares for a client with severe hemoglobinuria after an upper respiratory infection and fever. Diagnostic testing reveals degraded hemoglobin within the client's erythrocytes. Which hematological condition does the nurse suspect the client has? a. Glucose-6-phosphate dehydrogenase deficiency b. Sickle cell disease c. Aplastic anemia d. Polycythemia vera

a Glucose-6-phosphate dehydrogenase deficiency (G-6-PD) is the deficiency of a gene that produces an enzyme within the erythrocyte essential for membrane stability. Clients are asymptomatic and have normal hemoglobin levels and reticulocyte counts most of the time. However, after a normally-harmless virus or ingestion of a particular medication, clients develop pallor, jaundice, and hemoglobinuria (hemoglobin in the urine). The other answer choices are hematological diseases or conditions; however, these do not present in the same manner.

When assessing a client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential? a. Health history, such as bleeding, fatigue, or fainting b. Menstrual history c. Age and gender d. Lifestyle assessments, such as exercise routines

a When assessing a client with a disorder of the hematopoietic or the lymphatic system, it is essential to assess the client's health history. An assessment of drug history is essential because some antibiotics and cancer drugs contribute to hematopoietic dysfunction. Aspirin and anticoagulants may contribute to bleeding and interfere with clot formation. Because industrial materials, environmental toxins, and household products may affect blood-forming organs, the nurse needs to explore exposure to these agents. Menstrual history, age, gender, and lifestyle assessments, such as exercise routines and habits, do not directly affect the hematopoietic or lymphatic system.

A nurse in a long-term care facility is admitting a new resident who has a bleeding disorder. When planning this resident's care, the nurse should include what action?? a. Housing the resident in a private room b. Implementing a passive ROM program to compensate for activity limitation c. Implementing of a plan for fall prevention d. Providing the client with a high-fiber diet

c To prevent bleeding episodes, the nurse should ensure that an older adult with a bleeding disorder does not suffer a fall. Activity limitation is not necessarily required, however. A private room is not necessary and there is no reason to increase fiber intake.

A night nurse is reviewing the next day's medication administration record (MAR) of a hospital client who has hemophilia. The nurse notes that the MAR specifies both oral and subcutaneous options for the administration of a PRN antiemetic. What is the nurse's best action? a. Ensure that the day nurse knows not to give the antiemetic. b. Contact the prescriber to have the subcutaneous option discontinued. c. Reassess the client's need for antiemetics. d. Remove the subcutaneous route from the client's MAR.

b Injections must be avoided in clients with hemophilia. Consequently, the nurse should ensure that the prescriber makes the necessary change. The nurse cannot independently make a change to a client's MAR in most cases. Facilitating the necessary change is preferable to deferring to the day nurse.

A nurse in a long-term care facility is admitting a new resident who has a bleeding disorder. When planning this resident's care, the nurse should include what action?? a. Housing the resident in a private room b. Implementing a passive ROM program to compensate for activity limitation c. Implementing of a plan for fall prevention d. Providing the client with a high-fiber diet

c To prevent bleeding episodes, the nurse should ensure that an older adult with a bleeding disorder does not suffer a fall. Activity limitation is not necessarily required, however. A private room is not necessary and there is no reason to increase fiber intake.

A patient with chronic anemia has had many blood transfusions over the last 3 years. What type of transfusion reaction should the nurse monitor for that is commonly found in patients who frequently receive blood transfusions? a. Allergic reactions b. Acute hemolytic reaction c. Circulatory overload d. Febrile nonhemolytic reactions

d A febrile nonhemolytic reaction is caused by antibodies to donor leukocytes that remain in the unit of blood or blood component; it is the most common type of transfusion reaction. It occurs more frequently in patients who have had previous transfusions (exposure to multiple antigens from previous blood products) and in Rh-negative women who have borne Rh-positive children (exposure to an Rh-positive fetus raises antibody levels in the untreated mother).

A nurse is caring for a client who developed toxicity after long-term treatment with sulfasalazine for Crohn's disease. The client is experiencing fatigue, fever, chills, and headache and is at risk to develop opportunistic infections. Which condition has the client most likely developed? a. agranulocytosis b. leukopenia c. hemolytic anemia d. pernicious anemia

a Agranulocytosis refers specifically to a decreased production of granulocytes, neutrophils, basophils, and eosinophils. The most common cause of agranulocytosis is toxicity from drugs such as sulfonamides, chloramphenicol (Chloromycetin), antineoplastic, and some psychotropic medications. Clients with leukopenia have a general reduction in all WBCs. Clients with hemolytic anemia have a chronic premature destruction of erythrocytes. Pernicious anemia develops when a client lacks intrinsic factor, which normally is present in stomach secretions.

A nurse working with clients diagnosed with sickle cell disease notices that sickle cell crisis cases increase in the winter months. What is the primary pathophysiological reason for this? a. Colder temperatures slows the blood flow. b. Colder temperatures worsens sickling. c. Colder temperatures increases vessel pressures. d. Colder temperatures impairs oxygen uptake.

a Colder temperatures lead to vasoconstriction, which slows the blood flow. Colder temperatures do not worsen sickling or impair oxygen uptake. Vasoconstriction does increase vessel pressures but the vessel pressures are not the reason that sickle cell crisis increases with colder temperatures.

A client has a history of sickle cell anemia with several sickle cell crises over the past 10 years. Although it is a genetic disorder, sickle cell is found primarily in African Americans. How many African Americans does it affect in the United States? a. 1 in 625 b. 1 in 750 c. 1 in 900 d. 1 in 1000

a This common genetic disorder, found primarily in African Americans and also in people from Mediterranean and Middle Eastern countries, currently affects 1 in 625 African Americans in the United States.

A client with poorly controlled diabetes has developed end-stage kidney injury and consequent anemia. When reviewing this client's treatment plan, the nurse should anticipate the use of what drug? a. Magnesium sulfate b. Epoetin alfa c. Low-molecular-weight heparin d. Vitamin K

b The anemia that accompanies end-stage kidney injury is caused by decreased synthesis of erythropoietin. Exogenous forms are necessary to stimulate erythropoiesis. Heparin, vitamin K, and magnesium are not indicated in the treatment of kidney injury or the consequent anemia.

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? a. It is part of the required assessment information. b. It is important for the nurse to determine what type of foods the patient will eat. c. It may indicate deficiencies in essential nutrients. d. It will determine what type of anemia the patient has.

c A nutritional assessment is important, because it may indicate deficiencies in essential nutrients such as iron, vitamin B12, and folate.

A nurse is planning the care of a client with a diagnosis of sickle cell disease who has been admitted for the treatment of an acute vaso-occlusive crisis. What nursing diagnosis should the nurse prioritize in the client's plan of care? a. Risk for disuse syndrome related to ineffective peripheral circulation b. Functional urinary incontinence related to urethral occlusion c. Ineffective tissue perfusion related to thrombosis d. Ineffective thermoregulation related to hypothalamic dysfunction

c There are multiple potential complications of sickle cell disease and sickle cell crises. Central among these, however, is the risk of thrombosis and consequent lack of tissue perfusion. Sickle cell crises are not normally accompanied by impaired thermoregulation or genitourinary complications. Risk for disuse syndrome is not associated with the effects of acute vaso-occlusive crisis.

During a routine assessment of a patient diagnosed with anemia, the nurse observes the patient's beefy red tongue. The nurse is aware that this is a sign of what kind of anemia? a. Autoimmune b. Folate deficiency c. Iron deficiency d. Megaloblastic

d A beefy, red, sore tongue is a characteristic indicator of megaloblastic anemia. The nurse should assess for other signs such as fatigue, hypotension, and tachycardia. Safety issues should also be assessed because balance, coordination, and gait are affected.

While assessing a client, the nurse discovers the client has a history of restless leg syndrome. Which hematological condition does the nurse associate with this condition? a. Thalassemia b. Folate deficiency anemia c. Sickle cell disease d. Iron deficiency anemia

d Restless leg syndrome is common in as many as 24% of those with iron deficiency anemia.