Hematologic System
A nurse is caring for a group of hospitalized clients. Which client is at greatest risk for infection and sepsis? 1. 18-year-old who had an emergency splenectomy 2. 22-year-old with recently diagnosed sickle cell anemia 3. 38-year-old with hemolytic anemia 4. 40-year-old alcoholic with liver disease
1. Removal of the spleen causes the client to have reduced immune function. Without a spleen, people are less able to remove disease-causing organisms. Sickle cell anemia causes pain and discomfort owing to the changed cell morphology. Acute pain, especially at joints, is the greatest threat to this client. A low red blood cell (RBC) count can contribute to a client's risk for infection, but this client is more at risk for low oxygen levels and ensuing fatigue.The liver plays a role in blood coagulation. This client is more at risk for coagulation problems than for infection.
A client has a bone marrow biopsy done. Which nursing intervention is the priority postprocedure? 1.Applying pressure to the biopsy site 2. Inspecting the site for ecchymoses 3. Sending the biopsy specimens to the laboratory 4. Teaching the client about avoiding vigorous activity
1. The initial action should be to stop bleeding by applying pressure to the site. Inspecting for ecchymoses will be done after hemostasis has been achieved. Sending specimens to the laboratory will be done after hemostasis has been achieved. Teaching the client about activity levels will be done after hemostasis has been achieved.
A nurse is assessing a client for hematologic function risks. The nurse seeks to determine whether there is a risk that cannot be reduced or eliminated. Which clinical health history question does the nurse ask to obtain this information? 1."Do you seem to have excessive bleeding or bruising?" 2. "Does anyone in your family bleed a lot?" 3. "Tell me what you eat in a day." 4. "Where do you work?"
2. An accurate family history is important because many disorders that affect blood and blood clotting are inherited. Genetics cannot be changed. Excessive bleeding or bruising is a symptom, not a risk.
A newly admitted client has an elevated reticulocyte count. Which disorder does the nurse suspect in this client? 1. Aplastic anemia 2. Hemolytic anemia 3. Infectious process 4. Leukemia
2. An elevated reticulocyte count in the anemic client indicates that the bone marrow is responding appropriately to a decrease in the total red blood cell (RBC) mass and is prematurely destroying red blood cells. Therefore more immature RBCs are in circulation. Aplastic anemia is associated with a low reticulocyte count. A high white blood cell count is expected in clients with infection, while a low WBC is expected in clients with leukemia
A nurse is reviewing complete blood count (CBC) data for a 76-year-old client. Which decreased value causes concern because it is not age related? 1.Hemoglobin (Hgb) level 2. Platelet (thrombocyte) count 3. Red blood cell (RBC) count 4. White blood cell (WBC) response
2. Platelet counts do not generally change with age. Hemoglobin levels in men and women fall after middle age. Iron-deficient diets may play a role in this reduction. Total red blood cell (RBC) and white blood cell (WBC) counts (especially lymphocyte counts) are lower in older adults. The WBC count does not rise as high in response to infection in older adults as it does in younger people.
After reviewing the laboratory test results, the nurse calls the health care provider about which client? 1.44-year-old receiving warfarin (Coumadin) with an international normalized ratio (INR) of 3.0 2. 46-year-old with a fever and a white blood cell (WBC) count of 500/µl 3. 49-year-old with hemophilia and a platelet count of 150,000/mm3 4. 52-year-old who has had a hemorrhage with a reticulocyte count of 0.8%
2. This client is neutropenic and is at risk for sepsis unless interventions such as medications to improve WBC level and antibiotics are prescribed. The INR of 3.0 indicates a therapeutic Coumadin level. This platelet count is normal. An elevated reticulocyte count is expected after hemorrhage.
A nurse is teaching a client about what to expect during a bone marrow biopsy. Which statement by the nurse accurately describes the procedure? 1. "The doctor will place a small needle in your back and will withdraw some fluid." 2. "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." 3. "You will be alone because the procedure is a sterile one; we cannot allow additional people to contaminate the area." 4. "You will be sedated, so you will not be aware of anything."
2. This description is accurate. Proper expectations minimize the client's fear during the procedure. A very large-bore needle is used for a bone marrow biopsy, not a small needle. The puncture is made in the hip or in the sternum, not the back. The nurse, or sometimes a family member, is available to the client for support during a bone marrow biopsy. The procedure is sterile at the site of the biopsy, but others can be present without contamination at the site. A local anesthetic agent is injected into the skin around the site. The client may also receive a mild tranquilizer or a rapid-acting sedative (such as lorazepam [Ativan]) but will not be completely sedated. Clients are aware of what is happening during the procedure.
A client with anemia asks the nurse, "Do most people have the same number of red blood cells?" How does the nurse respond? 1."No, they don't." 2. "The number varies with gender, age, and general health." 3. "Yes, they do." 4. "You have fewer red blood cells because you have anemia."'
2. This is the most educational and reasonable response to the client's question. the first option is true, but not informative.
A client on anticoagulant therapy is being discharged. Which statement indicates that the client has a correct understanding of this therapy's purpose or action? 1. "It is to dissolve blood clots." 2. "It might cause me to get injured more often." 3. "It should prevent my blood from clotting." 4. "It will thin my blood."
3. Anticoagulants work by interfering with one or more steps involved in the blood clotting cascade. Thus, these agents prevent new clots from forming and limit or prevent extension of formed clots. Anticoagulants do not cause any change in the thickness or viscosity of the blood. Anticoagulants do not cause more injuries but may cause more bleeding and bruising when someone is injured. Anticoagulants do not dissolve clots, rather fibrinolytics do.
Which nursing action does the RN delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a female client with anemia? 1. Asking the client about the amount of blood loss with each menstrual period 2. Checking for sternal tenderness while applying fingertip pressure 3. Determining the respiratory rate before and after the client walks 20 feet 4. Monitoring her oral mucosa for pallor, bleeding, or ulceration
3. Assessment of respiratory rate before and after ambulation is within the scope of practice for UAP. UAP will report this information to the RN. Asking the client about the amount of blood loss with each menstrual period requires skilled assessment techniques and knowledge of normal parameters and should be done by the RN. Checking for sternal tenderness requires skilled assessment techniques and knowledge of normal parameters and should be done by the RN. Monitoring of oral mucosa requires skilled assessment techniques and knowledge of normal parameters and should be done by the RN.
A clinic nurse is discharging a 20-year-old client who had a bone marrow aspiration performed. What does the nurse advise the client to do? 1. "Avoid contact sports or activity that may traumatize the site for 24 hours." 2. "Inspect the site for bleeding every 4 to 6 hours." 3. "Place an ice pack over the site to reduce the bruising." 4. "Take a mild analgesic, such as 2 aspirin, for pain or discomfort at the site."
3. Ice to the site will help limit bruising and tissue damage during the first 24 hours postprocedure. Contact sports and traumatic activity needs to be excluded for 48 hours, or 2 days.The site should be carefully monitored by the client every 2 hours for the first 24 hours following the procedure.A mild analgesic is appropriate, but it should be aspirin free. Acetaminophen (Tylenol) would be a good choice.
A client with a low platelet count asks why platelets are important. How does the nurse answer? 1."Platelets make blood clots for you." 2. "Blood clotting is prevented by your platelets." 3. "The clotting process begins with your platelets." 4. "Your platelets finish the clotting process."
3. Platelets begin the blood clotting process by forming platelet plugs, but these platelet plugs are not clots and cannot provide complete hemostasis. Platelets do not clot blood. They are a part of the clotting process or cascade of coagulation.
Which client does the medical unit charge nurse assign to an LPN/LVN? 1.23-year-old scheduled for a bone marrow biopsy with conscious sedation 2. 35-year-old with a history of a splenectomy and a temperature of 100.9° F (38.3° C) 3. 48-year-old with chronic microcytic anemia associated with alcohol use 4. 62-year-old man with atrial fibrillation and an international normalized ratio (INR) of 6.6
3. This client has a chronic condition that is not considered life threatening. A bone marrow biopsy with conscious sedation requires more complex assessment or nursing care and should be assigned to RN staff members. A history of a splenectomy and a temperature require more complex assessment or nursing care and should be assigned to RN staff members. Atrial fibrillation and an international normalized ratio (INR) of 6.6 require more complex assessment or nursing care and should be assigned to RN staff members.
A nurse is assessing an adult client's endurance in performing ADLs. What question does the nurse ask the client? 1."Can you prepare your own meals?" 2."Has your weight changed by 5 pounds or more this year?" 3."How is your energy level-compared with last year?" 4."What medications do you take daily, weekly, monthly?"
3. This question from Gordon's Functional Health Pattern Assessment is an activity exercise question that correctly assesses endurance compared with self-assessment in the past. It is most likely to provide data about the client's ability and endurance with ADLs. The client may never have been able to prepare his or her own meals. This question does not really address endurance.
Which action does the RN delegate to unlicensed assistive personnel (UAP)? 1. Drawing a partial thromboplastin time (PTT) from a saline lock on a client with a pulmonary embolism 2. Performing a capillary fragility test to check vascular hemostatic function on a client with liver failure 3. Referring for counseling a client with a daily alcohol consumption of 12 beers a day 4. Reporting any bleeding noted when catheter care is given to a client with a history of hemophilia
4. Reporting findings during routine care is expected and required of unlicensed staff members. Drawing a partial thromboplastin time is more complex and should be done by licensed nursing staff. Performing a capillary fragility test is more complex and should be done by licensed nursing staff. Referring a client for alcohol counseling is more complex and should be done by licensed nursing staff.
A client with anemia asks, "Why am I feeling tired all the time?" How does the nurse respond? 1. "How many hours are you sleeping at night?" 2. "You are not getting enough iron." 3. "You need to rest more when you are sick." 4. "Your cells are delivering less oxygen than you need."
4. The single most common symptom of anemia is fatigue. This problem occurs because oxygen delivery to cells is less than is required to meet normal oxygen needs.
A nurse is starting the shift by making rounds. Which client does the nurse decide to assess first? 1.42-year-old with anemia who is reporting shortness of breath when ambulating down the hallway 2. 47-year-old who recently had a Rumpel-Leede test and is requesting a nurse to "look at the bruises on my arm" 3. 52-year-old who has just had a bone marrow aspiration and is requesting pain medication 4. 59-year old who has a nosebleed and is receiving heparin to treat a pulmonary embolism
4. This client may be experiencing the bleeding as a result of excessive anticoagulation and should be assessed for the severity of the situation before the other clients, whose conditions are stable, are assessed. regarding option number 3, Making clients wait for pain medication is not desirable, but in this scenario, the client who is bleeding is the higher priority. This client should be next on the nurse's "to do" list.
A nurse is assessing the nutritional status of a client with anemia. How does the nurse obtain information about the client's diet? 1.Asks the client to rate his or her diet on a scale of 1 (poor) to 10 (excellent) 2. Determines who prepares the client's meals and plans an interview with him or her 3. From a prepared list, finds out the client's food preferences 4. Has the client write down everything he or she has eaten for the past week
4. This method is the most accurate way to find out what the client likes and dislikes, as well as what the client has been eating. It will provide information about "junk" food intake, as well as about the client's protein, vitamin, and mineral intake. the third option method of dietary analysis provides a list of what the client enjoys eating, not necessarily what the client has been eating. The client may like steak but may be unable to afford it.
A client is scheduled for a bone marrow aspiration. What does the client's nurse do before taking the client to the treatment room for the biopsy? 1. Cleans the biopsy site with an antiseptic or povidone-iodine (Betadine) 2. Holds the client's hand and asks about concerns 3. Reviews the client's platelet (thrombocyte) count 4. Verifies that the client has given informed consent
4. Verifying informed consent must be done before the procedure can be performed. A signed permit must be on the client's chart. Cleaning the biopsy site is done before the procedure but is not the first thing that should be done. It is not done until consent is verified. It will be done just before the procedure is performed.
When assessing a patient's nutritional-metabolic pattern related to hematologic health, the nurse would: A. Insepct the skin for petechiae B. ask about joint pain C. assess for Vit C deficiency D. Determine if the pt can perform ADLs
A. Any changes in the skin's texture or color should be explored when assessing the patient's nutritional-metabolic pattern related to hematologic health. The presence of petechiae or ecchymotic areas could be indicative of hematologic deficiencies related to poor nutritional intake or related causes.
Which of the following patients is most likely to experience anemia with an etiology of increased destruction of red blood cells? A. An African American man who has a diagnosis of sickle cell disease B. A 59-year-old man whose alcoholism has precipitated folic acid deficiency C. A 30-year-old woman with a history of "heavy periods" accompanied by anemia D. A 3-year-old child whose impaired growth and development is attributable to thalassemia
A. The etiology of sickle cell anemia involves increased hemolysis. Thalassemias and folic acid deficiencies cause a decrease in erythropoiesis whereas the anemia surrounding menstruation is a direct result of blood loss.
The nurse receives a physician's order to transfuse fresh frozen plasma to a patient suffering from an acute blood loss. Which of the following procedures is most appropriate for infusing this blood product? A. Infuse the fresh frozen plasma as rapidly as the patient will tolerate. B. Hang the fresh frozen plasma as a piggyback to the primary IV solution. C. Infuse the fresh frozen plasma as a piggyback to a primary solution of normal saline. D. Hang the fresh frozen plasma as a piggyback to a new bag of primary IV solution without KCl.
A. The fresh frozen plasma should be administered as rapidly as possible and should be used within 2 hours of thawing. Fresh frozen plasma is infused using any straight-line infusion set. Any existing IV should be interrupted while the fresh frozen plasma is infused, unless a second IV line has been started for the transfusion.
Before beginning a transfusion of RBCs, which of the following actions by the nurse would be of highest priority to avoid an error during this procedure? A. Check the identifying information on the unit of blood against the patient's ID bracelet. B. Select new primary IV tubing primed with lactated Ringer's solution to use for the transfusion. C. Remain with the patient for 60 minutes after beginning the transfusion to watch for signs of a transfusion reaction. D. Add the blood transfusion as a secondary line to the existing IV and use the IV controller to maintain correct flow.
A. The patient's identifying information (name, date of birth, medical record number) on the ID bracelet should exactly match the information on the blood bank tag that has been placed on the unit of blood. If any information does not match, the transfusions should not be hung because of possible error and risk to the patient.
Results of a patient's most recent blood work indicate an elevated neutrophil level. You recognize that this diagnostic finding most likely suggests: A. Hypoxemia B. an infection C. risk of hypocoagulation D. an acute thrombotic event
B. An increase in neutrophil count most commonly occurs in response to infection or inflammation. Hypoxemia and coagulation do not directly affect neutrophil production.
You are providing care for older adults on a subacute, geriatric medicine unit. Which of the following effects is aging likely to have on hematologic function of older adults? A. Hypercoagulability B. decreased hemoglobin C. decreased blood volume D. decreased WBC count
B. An individual with type A blood has A antigens, not A antibodies, on his RBCs. An AB transfusion would result in agglutination, but he may be transfused with either type A or type O.
Before starting a transfusion of packed red blood cells for an anemic patient, the nurse would arrange for a peer to monitor his or her other assigned patients for how many minutes when the nurse begins the transfusion? A. 5 B. 15 C. 30 D. 60
B. As part of standard procedure, the nurse remains with the patient for the first 15 minutes after starting a blood transfusion. Patients who are likely to have a transfusion reaction will more often exhibit signs within the first 15 minutes that the blood is infusing.
The blood bank notifies the nurse that the two units of blood ordered for an anemic patient are ready for pick up. The nurse should take which of the following actions to prevent an adverse effect during this procedure? A. Immediately pick up both units of blood from the blood bank. B. Correct Infuse the blood slowly for the first 15 minutes of the transfusion. C. Regulate the flow rate so that each unit takes at least 4 hours to transfuse. D. Set up the Y-tubing of the blood set with dextrose in water as the flush solution.
B. Because a transfusion reaction is more likely to occur at the beginning of a transfusion, the nurse should initially infuse the blood at a rate no faster than 2 ml/min and remain with the patient for the first 15 minutes after hanging a unit of blood.
A patient with a diagnosis of hemophilia had a fall down an escalator earlier in the day and is now experiencing bleeding in her left knee joint. The emergency nurse's immediate response to this should include A. Immediate transfusion of platelets. B. Resting the patient's knee to prevent hemarthroses. C. Assistance with intracapsular injection of corticosteroids. D. Range-of-motion exercises to prevent thrombus formation.
B. In patients with hemophilia, joint bleeding requires resting of the joint in order to prevent deformities from hemarthrosis. Clotting factors, not platelets or steroids, are administered. Thrombus formation is not a central concern in a patient with hemophilia.
Caring for a patient with a diagnosis of polycythemia vera will likely require the nurse to A. Encourage deep-breathing and coughing. B. Assist with or perform phlebotomy at the bedside. C. Teach the patient how to maintain a low-activity lifestyle. D. Perform thorough and regularly scheduled neurologic assessments.
B. Primary polycythemia may often require phlebotomy in order to reduce blood volume. The increased risk of thrombus formation that accompanies the disease requires regular exercises and ambulation. Deep-breathing and coughing exercises do not directly address the etiology or common sequelae of polycythemia, and neurologic manifestations are not typical.
When caring for a patient with metastatic cancer, the nurse notes a hemoglobin level of 8.7 g/dl and hematocrit of 26%. The nurse would place highest priority on initiating interventions that will reduce which of the following? A. thirst B. fatigue C. headache D. abdominal pain
B. The patient with a low hemoglobin and hematocrit is anemic and would be most likely to experience fatigue. Fatigue develops because of the lowered oxygen-carrying capacity that leads to reduced tissue oxygenation to carry out cellular functions.
The nurse notes a physician's order written at 10:00 am for two units of packed red blood cells to be administered to a patient who is anemic as a result of chronic blood loss. If the transfusion is picked up at 11:30 am, the nurse should plan to hang the unit no later than which of the following times? A. 11:45 am B. 12:00 noon C. 12:30 pm D. 15:30 pm
B. noon. The nurse must hang the unit of packed red blood cells within 30 minutes of signing them out from the blood bank.
A 30-year-old patient has undergone a splenectomy as a result of injuries suffered in a motor vehicle accident. Which of the following phenomena is likely to result from the absence of the patient's spleen (select all that apply)? Impaired fibrinolysis Increased platelet levels Increased eosinophil levels Fatigue and cold intolerance Impaired immunologic function
B., E.: Splenectomy can result in increased platelet levels and impaired immunologic function as a consequence of the loss of storage and immunologic functions of the spleen. Fibrinolysis, fatigue, and cold intolerance are less likely to result from the loss of the spleen since coagulation and oxygenation are not primary responsibilities of the spleen
Which of the following nursing interventions should the nurse prioritize in the care of a 30-year-old woman who has a diagnosis of immune thrombocytopenic purpura (ITP)? A. Administration of packed red blood cells B. Administration of clotting factors VIII and IX C. Administration of oral or intravenous corticosteroids D. Maintenance of reverse isolation and application of standard precautions
C. Common treatment modalities for ITP include corticosteroid therapy to suppress the phagocytic response of splenic macrophages. Blood transfusions, administration of clotting factors, and reverse isolation are not interventions that are indicated in the care of patients with ITP.
When preparing to administer an ordered blood transfusion, the nurse selects which of the following intravenous solutions to use when priming the blood tubing? A. Lactated Ringer's B. 5% Dextrose in water C. 0.9% NaCl D. 0.45% NaCl
C. The blood set should be primed before the transfusion with 0.9% sodium chloride, also known as normal saline. It is also used to flush the blood tubing after the infusion is complete to ensure the patient receives blood that is left in the tubing when the bag is empty.
The nurse is caring for a patient who is to receive a transfusion of two units of packed red blood cells. After obtaining the first unit from the blood bank, the nurse would ask which of the following health team members in the nurses' station to assist in checking the unit before administration? A. unit secretary B. a phlebotomist C. a physician's assistant D. another RN
D. Before hanging a transfusion, the registered nurse must check the unit with another RN or with a licensed practical (vocational) nurse, depending on agency policy.
When assessing lab values on a patient admitted with septicemia, the nurse would expect to find A. Increased platelets. B. Decreased red blood cells. C. Decreased erythrocyte sedimentation rate (ESR). D. Increased bands in the white blood cell (WBC) differential (shift to the left).
D. When infections are severe, such as in septicemia, more granulocytes are released from the bone marrow as a compensatory mechanism. To meet the increased demand, many young, immature polymorphonuclear neutrophils (bands) are released into circulation. WBCs are usually reported in order of maturity, with the less mature forms on the left side of a written report. Hence, the term "shift to the left" is used to denote an increase in the number of bands.