Hematological Problems P2

16. A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep-vein thrombosis is diagnosed with heparin-induced thrombocytopenia and thrombosis syndrome (HITTS). What does the nurse anticipate that the physician will order? a. Use saline for flushing intravenous (IV) lines. b. Give low-molecular weight (LMW) heparin. c. Discontinue the warfarin. d. Administer platelet transfusions.

ANS: A All heparin is discontinued when the HITTS is diagnosed. The patient should be instructed never to receive heparin or LMW heparin; therefore, saline will be ordered for flushing IV lines. PTS: 1 DIF: Cognitive Level: Comprehension REF: page 804 OBJ: 6 TOP: Nursing Process: Implementation MSC: CRNE: CH-8

32. A patient with chemotherapy-induced neutropenia is placed in a private room, and protective isolation is instituted. The care plan the nurse develops with the patient is based on the knowledge that which of the following sources of infection is the most common in patients with neutropenia? a. Normally nonpathogenic microorganisms of the patient's own flora b. Microorganisms that are not sensitive to broad-spectrum antibiotics c. Microorganisms transmitted to the patient by the hands of health care providers d. Microorganisms transmitted to the patient by health care providers with transmissible infections

ANS: A An important consideration in the care of a neutropenic patient is the determination of the best means to protect the patient whose own defences against infection are compromised. To accomplish this goal, the following principles must be kept in mind: (1) the patient's normal flora are the most common source of microbial colonization and infection; (2) transmission of organisms from humans most commonly occurs by direct contact with the hands; (3) air, food, water, and equipment provide additional opportunities for infection transmission; and (4) health care providers with transmissible illnesses and other patients with infections can also be sources of infection transmission under certain conditions. PTS: 1 DIF: Cognitive Level: Comprehension REF: page 818 OBJ: CH-9 TOP: Nursing Process: Assessment MSC: CRNE: CH-8

26. A patient's family member asks the nurse what caused the patient to develop disseminated intravascular coagulation (DIC). What does the nurse tell the family member about DIC? a. It is caused by an abnormal activation of clotting. b. It occurs when the immune system attacks platelets. c. It is a complication of cancer chemotherapy. d. It is caused when hemolytic processes destroy erythrocytes.

ANS: A DIC is an abnormal response of the clotting cascade stimulated by a variety of diseases or disorders. PTS: 1 DIF: Cognitive Level: Comprehension REF: page 812 OBJ: 8 TOP: Nursing Process: Implementation MSC: CRNE: CH-8

13. The physician orders transfusion with packed RBCs for a patient who has severe anemia resulting from a bleeding peptic ulcer. What is the most important nursing action to prevent a transfusion reaction when administering the blood? a. Verify and document patient identification. b. Keep the blood chilled during administration. c. Administer the blood at a rate of no more than 2 mL/min. d. Stay with the patient during the first 15 minutes of the transfusion.

ANS: A Improper identification is responsible for 90% of hemolytic transfusion reactions. PTS: 1 DIF: Cognitive Level: Comprehension REF: page 832 OBJ: 16 TOP: Nursing Process: Implementation MSC: CRNE: CH-54

6. After teaching the patient about taking oral iron preparations for a moderate iron-deficiency anemia, which of the following patient statements indicates to the nurse that additional instruction is needed? a. "I will contact my doctor if my stools start to turn black." b. "I will call the doctor if the tablets cause a lot of stomach upset." c. "I will increase my fluid intake if the iron tablets make me constipated." d. "I should take the iron tablets with orange juice about an hour before meals."

ANS: A It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the doctor about this. PTS: 1 DIF: Cognitive Level: Application REF: page 792 OBJ: 3 TOP: Nursing Process: Evaluation MSC: CRNE: NCP-14

4. A 52-year-old patient has pernicious anemia with long-standing weakness and paraesthesia of the feet and hands. The nurse determines that expected outcomes related to knowledge of the therapeutic regimen have been met when the patient states which of the following? a. "I will need to have cobalamin (B12) injections regularly for the rest of my life." b. "I will increase sources of cobalamin (B12), such as muscle meats and liver, in my diet." c. "The feeling in my hands and feet will return when my hemoglobin level returns to normal." d. "I should plan for only part-time employment because of the chronic fatigue that pernicious anemia causes."

ANS: A Pernicious anemia prevents the absorption of vitamin B12, and the patient requires injections or intranasal administration of cobalamin. PTS: 1 DIF: Cognitive Level: Application REF: page 793 OBJ: 2 TOP: Nursing Process: Assessment MSC: CRNE: CH-8

24. Laboratory studies related to coagulation are performed on a patient with a bleeding disorder. The nurse explains to the patient that von Willebrand's disease can be differentiated from other types of hemophilia by evaluating which of the following laboratory results? a. Bleeding time b. Platelet count c. Prothrombin time d. Partial thromboplastin time

ANS: A The bleeding time is affected by von Willebrand's disease. Platelet count, prothrombin time, and partial thromboplastin time are normal in von Willebrand's disease. PTS: 1 DIF: Cognitive Level: Application REF: page 811, Table 33-19 OBJ: 7 TOP: Nursing Process: Assessment MSC: CRNE: CH-6

15. Fifteen minutes after a transfusion of packed RBCs is started, a patient develops tachycardia and tachypnea, and complains of back pain and feeling warm. What is the nurse's priority action? a. Discontinue transfusion, and infuse normal saline. b. Administer oxygen therapy at a high flow rate. c. Slow the transfusion rate, and reassess the patient in 15 minutes. d. Stop the blood, and discard the used bag and tubing in a biohazard container.

ANS: A The first action should be to disconnect the transfusion and infuse normal saline to keep the line open and maintain the patient's blood pressure. The other actions are also needed but are not the highest priority. PTS: 1 DIF: Cognitive Level: Application REF: page 833 OBJ: 16 TOP: Nursing Process: Implementation MSC: CRNE: CH-54

23. A patient with type A hemophilia has been admitted to the hospital with severe pain and swelling in his right knee. To prevent joint deformity during the initial care of the patient, what should the nurse do? a. Immobilize the knee. b. Elevate the right lower limb on pillows. c. Perform passive range of motion to the knee. d. Have the patient perform isometric exercises of the affected leg against a footboard.

ANS: A The initial action should be total rest of the knee to minimize bleeding. PTS: 1 DIF: Cognitive Level: Application REF: page 811 OBJ: 7 TOP: Nursing Process: Implementation MSC: CRNE: CH-40

35. During care of the patient with multiple myeloma, what is an important nursing intervention? a. Limiting activity to prevent pathological fractures b. Maintaining a fluid intake of 3 to 4 L/day to dilute calcium load c. Assessing for changes in size and characteristics of lymph nodes d. Administering narcotic analgesics continuously to control bone pain

ANS: B A high fluid intake and urinary output help prevent the complications of kidney stones arising from hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. PTS: 1 DIF: Cognitive Level: Comprehension REF: page 831 OBJ: 14 TOP: Nursing Process: Implementation MSC: CRNE: CH-8

7. A 42-year-old patient is admitted to the hospital with idiopathic aplastic anemia. What is an appropriate collaborative problem for the nurse to identify for the patient? a. Potential complication: seizures b. Potential complication: hemorrhage c. Potential complication: neurogenic shock d. Potential complication: pulmonary edema

ANS: B Because the patient with aplastic anemia has pancytopenia, the patient is at risk for bleeding and infection. PTS: 1 DIF: Cognitive Level: Application REF: page 795 OBJ: 2 TOP: Nursing Process: Planning MSC: CRNE: CH-8

30. A patient receiving chemotherapy for acute lymphocytic leukemia has pancytopenia, and filgrastim (Neupogen) is prescribed. The nurse teaches the patient that the reason for the use of the medication is which of the following? a. Remission of the leukemia b. Improvement in the number and function of neutrophils c. Replacement of abnormal stem cells in the bone marrow with normal cells d. Prevention of hemorrhage complications in patients with thrombocytopenia

ANS: B Filgrastim increases the neutrophil count and function in neutropenic patients. PTS: 1 DIF: Cognitive Level: Comprehension REF: page 818 OBJ: 9 TOP: Nursing Process: Implementation MSC: CRNE: CH-44

38. Which nutrient plays a role in helping mature RBCs in erythropoiesis? a. Iron b. Folic acid c. Pyridoxine d. Ascorbic acid

ANS: B Folic acid's role in erythropoiesis is to cause RBC maturation. PTS: 1 DIF: Cognitive Level: Knowledge REF: page 790, Table 33-5 OBJ: 1 TOP: Nursing Process: Assessment MSC: CRNE: CH-8

12. During the admission assessment of a patient who has an Hb of 4.7 mmol/L (7.6 g/dL) and jaundice of the sclera, what laboratory results would the nurse assess? a. Stool occult blood b. Bilirubin level c. Schilling test d. Gastric analysis testing

ANS: B Jaundice is caused by the elevation of bilirubin level associated with RBC hemolysis. The presence of jaundice suggests a hemolytic anemia, rather than gastrointestinal bleeding or cobalamin deficiency, as the cause of the anemia. PTS: 1 DIF: Cognitive Level: Application REF: page 797 OBJ: 1 TOP: Nursing Process: Assessment MSC: CRNE: CH-6

21. The nurse identifies a nursing diagnosis of risk for injury related to medical interventions for a patient with immune thrombocytopenic purpura. What is an appropriate nursing intervention that addresses the etiology of this nursing diagnosis? a. Use a soft-bristled toothbrush and cotton swabs for mouth care. b. Limit the number of venipunctures by using an intermittent-infusion device. c. Assess the patient during the platelet transfusion for symptoms of transfusion reactions. d. Assess the patient's mucous membranes and skin each shift to detect the presence of bleeding.

ANS: B Limit the number of venipunctures; intramuscular or subcutaneous injections should be avoided because of the risk for bleeding. PTS: 1 DIF: Cognitive Level: Application REF: page 808 OBJ: 6 TOP: Nursing Process: Implementation MSC: CRNE: HW-24

17. During treatment of the patient with an acute exacerbation of polycythemia vera, what is a critical nursing intervention? a. Administer oxygen. b. Evaluate fluid balance. c. Administer anticoagulants. d. Administer parenteral iron.

ANS: B Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. PTS: 1 DIF: Cognitive Level: Comprehension REF: page 803 OBJ: 5 TOP: Nursing Process: Implementation MSC: CRNE: CH-34

5. A patient with chronic lymphocytic leukemia is hospitalized for treatment of severe hemolytic anemia. What is an appropriate nursing intervention for the patient? a. Provide a diet high in vitamin K and folic acid. b. Plan care to alternate periods of rest and activity. c. Isolate the patient from visitors and other patients. d. Encourage increased intake of fluid and fibre in the diet.

ANS: B Nursing care for patients with anemia should alternate periods of rest and activity to maintain patient mobility without causing undue fatigue. PTS: 1 DIF: Cognitive Level: Application REF: page 789, Nursing Care Plan 33-1 OBJ: 4 TOP: Nursing Process: Implementation MSC: CRNE: CH-13

34. A 45-year-old woman with chronic myelogenous leukemia is considering the possibility of treatment with a bone marrow transplant from a human leukocyte antigen-matched sibling. To assist the patient with treatment decisions, what is the best approach for the nurse to use? a. Emphasize the positive outcomes of a bone marrow transplant. b. Ensure that the patient understands the risks of treatment-related death or treatment failure. c. Explain that a cure is not possible with any other type of treatment except a bone marrow transplant. d. Encourage the patient to ask the physician about new, experimental treatments for leukemia that do not involve total body irradiation.

ANS: B Offering the patient an opportunity to ask questions or discuss concerns about hematopoietic stem cell transplantation will encourage the patient to voice concerns about this treatment and will also allow the nurse to assess whether the patient needs more information about the procedure. PTS: 1 DIF: Cognitive Level: Application REF: page 823 OBJ: 12 TOP: Nursing Process: Implementation MSC: CRNE: HW-26

8. A patient with sickle cell anemia is admitted to the hospital in crisis with severe abdominal pain. While caring for the patient, what is it most important for the nurse to do? a. Limit the patient's intake of oral fluids. b. Evaluate the effectiveness of narcotic analgesics. c. Encourage the patient to ambulate as much as tolerated. d. Teach the patient about high-protein, high-calorie foods.

ANS: B Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. PTS: 1 DIF: Cognitive Level: Application REF: page 799 OBJ: 4 TOP: Nursing Process: Evaluation MSC: CRNE: CH-52

20. While a patient with severe acquired thrombocytopenia is receiving platelet transfusions, the nurse recognizes that a platelet transfusion reaction may be present when the patient experiences which of the following signs? a. Flushing, itching, and urticaria b. Sudden onset of chills and fever c. Urticaria, wheezing, and hypotension d. Tachycardia, tachypnea, and hemoglobinuria

ANS: B Sudden onset of both chills and fever indicates a transfusion reaction. PTS: 1 DIF: Cognitive Level: Comprehension REF: page 834, Table 33-35 OBJ: 16 TOP: Nursing Process: Assessment MSC: CRNE: CH-54

29. What is the most appropriate nursing intervention to assess for the presence of infection in a patient with neutropenia? a. Monitor WBCs daily. b. Monitor temperature every 4 hours. c. Monitor the skin for temperature and diaphoresis. d. Monitor the mouth and perianal area every shift for signs of redness and swelling.

ANS: B The earliest sign of infection in a neutropenic patient is an elevation in temperature. Patients with neutropenia (low neutrophil count) are susceptible to infection and may be febrile. PTS: 1 DIF: Cognitive Level: Comprehension REF: page 817 OBJ: 9 TOP: Nursing Process: Implementation MSC: CRNE: CH-13

14. A patient receiving a transfusion of whole blood develops chills and fever, headache, and anxiety 30 minutes after the transfusion is started. Which of the following does the nurse implement after stopping the transfusion? a. Send a urine specimen to the laboratory. b. Administer acetaminophen (Tylenol). c. Give diphenhydramine (Benadryl). d. Draw blood for a new crossmatch.

ANS: B The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. PTS: 1 DIF: Cognitive Level: Comprehension REF: page 834, Table 33-35 OBJ: 16 TOP: Nursing Process: Implementation MSC: CRNE: CH-54

27. During treatment of the patient who has sepsis-induced DIC with moderate bleeding, on what would the nurse expect the initial collaborative care will focus? a. Administration of heparin to reduce intravascular clotting b. Treatment of the infectious process with IV antibiotics c. Infusion of whole blood to replace clotting factors and RBCs d. Supportive management of symptoms until the DIC is resolved

ANS: B Treatment of the acute sepsis is essential to resolving the DIC and will be the major focus of collaborative care. Heparin administration is controversial in DIC, although it may be used if the DIC does not resolve and clotting factors continue to decrease. PTS: 1 DIF: Cognitive Level: Comprehension REF: pages 814-815 OBJ: 8 TOP: Nursing Process: Implementation MSC: CRNE: CH-22

19. Of the following patients waiting to be admitted by the emergency department nurse, which one requires the most rapid assessment and care by the nurse? a. The patient with a history of sickle cell anemia who has had nausea and diarrhea for 24 hours b. The patient who has chemotherapy-induced neutropenia and a temperature of 38°C c. The patient with thrombocytopenia who has oozing after having a tooth extracted d. The patient with hemophilia A who has ankle swelling after twisting the ankle

ANS: C A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. PTS: 1 DIF: Cognitive Level: Application REF: page 815 OBJ: 9 TOP: Nursing Process: Assessment MSC: CRNE: CH-22

11. A patient who has experienced an acute blood loss exhibits a normal supine blood pressure and pulse at rest but complains of postural hypotension and has a pulse of 110 beats/min when exercising. The nurse knows that these signs and symptoms are manifestations of what percentage of blood loss? a. 10% b. 20% c. 30% d. 40%

ANS: C A patient who has experienced an acute blood loss and exhibits a normal supine blood pressure and pulse at rest but complains of postural hypotension and has a pulse of 110 beats/min when exercising has lost approximately 30% of their total blood volume. PTS: 1 DIF: Cognitive Level: Comprehension REF: page 796, Table 33-11 OBJ: 3 TOP: Nursing Process: Assessment MSC: CRNE: CH-6

36. A patient with non-Hodgkin's lymphoma develops a platelet count of 10,000 cells/microlitre during chemotherapy. Based on this finding, what is an appropriate nursing intervention for the patient? a. Provide oral hygiene every 2 hours. b. Check the temperature every 4 hours. c. Check all stools for occult blood. d. Encourage fluids to 3000 mL/day.

ANS: C Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. PTS: 1 DIF: Cognitive Level: Application REF: page 808, Nursing Care Plan 33-2 OBJ: 13 TOP: Nursing Process: Implementation MSC: CRNE: CH-13

33. A patient with neutropenia has a nursing diagnosis of risk for infection. What is the most important nursing intervention in the prevention of transmission of harmful pathogens to the patient? a. Prohibiting the oral intake of fresh fruits and vegetables b. Maintaining strict administration schedules of prophylactic antibiotics c. Strict and frequent handwashing by all persons having contact with the patient d. Creating a "sterile" environment for the patient with the use of laminar airflow rooms

ANS: C Infection control measures such as handwashing are necessary for the patient with neutropenia. PTS: 1 DIF: Cognitive Level: Comprehension REF: page 816, Table 33-24 OBJ: 9 TOP: Nursing Process: Implementation MSC: CRNE: HW-2

9. A 21-year-old patient is having a sickle cell crisis for the first time in many years. He asks the nurse why the sickling causes such pain. The nurse should explain that the pain of sickling is caused by which of the following? a. Spasms of the blood cells as they change shape b. Deposition of sickled red cells in the bone marrow c. Tissue hypoxia caused by small blood vessel occlusion d. Bacterial or viral infections of organs that caused the sickling

ANS: C The pain associated with a sickle cell crisis is caused by ischemia, as the sickled cells occlude small blood vessels and capillaries. PTS: 1 DIF: Cognitive Level: Application REF: page 798 OBJ: 4 TOP: Nursing Process: Implementation MSC: CRNE: CH-8

1. A patient with a history of iron-deficiency anemia who has not taken iron supplements for several years is experiencing increased fatigue and dizziness. What would the nurse expect the patient's laboratory findings to include? a. Hematocrit 0.38 (38%) b. Red blood cell (RBC) count 4,500,000/µL c. Hemoglobin (Hb) 86 g/L d. Normal RBC indices

ANS: C The patient's clinical manifestations indicate moderate anemia, which is consistent with an Hb of 60 to 100 g/L. PTS: 1 DIF: Cognitive Level: Analysis REF: page 786 OBJ: 2 TOP: Nursing Process: Assessment MSC: CRNE: CH-6

3. Which one of the following groups of people is at an increased risk for developing iron-deficiency anemia? a. Postmenopausal women b. Middle-class people c. Pregnant women d. School-aged males

ANS: C Those at risk for the development of iron-deficiency anemia are premenopausal and pregnant women, people from low socioeconomic backgrounds, older adults, and individuals experiencing blood loss. PTS: 1 DIF: Cognitive Level: Comprehension REF: page 790 OBJ: 1 TOP: Nursing Process: Assessment MSC: CRNE: CH-8

22. When preparing a patient for a blood transfusion, the nurse will prepare the blood. Which IV solution would the nurse prepare to administer in a Y-type tubing adjacent to the blood? a. Dextrose 5% b. Lactated Ringer's c. Normal saline d. Dextrose 10%

ANS: C When preparing a patient for a blood transfusion, the nurse will prepare the blood and attach normal saline to Y-type tubing adjacent to the blood for administration. PTS: 1 DIF: Cognitive Level: Application REF: page 832 OBJ: 16 TOP: Nursing Process: Implementation MSC: CRNE: CH-54

31. A 64-year-old patient with newly diagnosed acute myelogenous leukemia (AML) is undergoing induction therapy with chemotherapeutic agents. He tells the nurse that he is so sick from the induction therapy that he wonders if it is worth it. What is the best response to this patient? a. "I know you feel really ill right now, but after this therapy, your disease will go into a remission, and you will feel normal again." b. "Induction therapy is very aggressive and causes the most side effects, so when this phase is completed, you won't feel so ill." c. "Your type of leukemia has a survival rate of up to 10 years if aggressive therapy is started, so the effects of treatment should be worth it to you." d. "I know that this phase is very difficult for you, but the treatment is necessary to achieve control of your disease so that you will have some time to make choices about your life."

ANS: D AML is very aggressive, and survival after diagnosis is short without treatment. PTS: 1 DIF: Cognitive Level: Application REF: page 820 OBJ: 11 TOP: Nursing Process: Implementation MSC: CRNE: CH-8

2. When the nurse discusses foods high in iron with a patient who has iron-deficiency anemia, the patient tells the nurse that she prepares low-cholesterol foods for her family and probably does not eat enough meat to meet her iron requirements. It is an appropriate goal for the patient to increase dietary intake of which of the following? a. Eggs and fish b. Nuts and cornmeal c. Milk and milk products d. Legumes and dried fruit

ANS: D Legumes and dried fruits are high in iron and low in fat and cholesterol. PTS: 1 DIF: Cognitive Level: Application REF: page 790, Table 33-5 OBJ: 3 TOP: Nursing Process: Implementation MSC: CRNE: CH-35

25. When caring for a patient with hemophilia, the nurse teaches the patient to seek immediate medical attention on experiencing which of the following signs? a. Fever b. A sore throat c. Bleeding gums d. Dark, tarry stools (melena)

ANS: D Melena is a sign of gastrointestinal bleeding and requires further assessment. PTS: 1 DIF: Cognitive Level: Comprehension REF: page 812 OBJ: 7 TOP: Nursing Process: Assessment MSC: CRNE: CH-8

18. For which one of the following lab results would the nurse expect to see abnormal results in a patient who has hemophilia? a. Thrombin time b. Platelet count c. Prothrombin time d. Partial thromboplastin time

ANS: D Partial thromboplastin time is prolonged in patients with hemophilia because of a deficiency in any intrinsic clotting system factor. Prothrombin time, thrombin time, and platelet count are expected to be normal in a patient with hemophilia. PTS: 1 DIF: Cognitive Level: Application REF: page 811, Table 33-19 OBJ: 7 TOP: Nursing Process: Assessment MSC: CRNE: CH-8

10. During discharge teaching for the patient with neutropenia, which of the following issues should the nurse include? a. Caffeine and alcohol intake b. Excessive dietary iron intake c. Limiting fluids to 2 L per day d. Exposure to crowds

ANS: D Patients with neutropenia should be instructed to avoid crowds and people who have colds, flu, or infections. If they are in a public area, they should be taught to wear a mask. PTS: 1 DIF: Cognitive Level: Comprehension REF: page 818, Table 33-25 OBJ: 9 TOP: Nursing Process: Implementation MSC: CRNE: HW-8

28. A patient with myelodysplastic syndrome has laboratory values that indicate total bone marrow suppression. The nurse identifies a nursing diagnosis of risk for infection based on which of the following findings? a. Basophils 120 cells/mL b. Monocytes 360 cells/mL c. Neutrophils 4000 cells/mL d. White blood cell (WBC) count 2.8 109 cells/L (2800 cells/microlitre)

ANS: D The low WBC count indicates a risk for infection. The nurse should notify the physician and expect an order to check the differential WBC count. PTS: 1 DIF: Cognitive Level: Application REF: page 819 OBJ: 10 TOP: Nursing Process: Assessment MSC: CRNE: CH-6

37. A 26-year-old patient with stage II Hodgkin's disease asks the nurse how long he probably has to live. What is the best response to the patient? a. "No one can predict when someone will die, so try to focus on the present." b. "It will depend on how your disease responds to chemotherapy, but most patients do well." c. "If your initiation chemotherapy is effective, it is possible to have at least a 5-year remission." d. "Most patients with your stage of Hodgkin's disease are treated successfully."

ANS: D The survival rate is almost 90% in patients with the early stages of Hodgkin's lymphoma. PTS: 1 DIF: Cognitive Level: Application REF: page 827 OBJ: 13 TOP: Nursing Process: Implementation MSC: CRNE: CH-8