Heme NCLEX
What are the risk factors for the development of leukemia? (Select all that apply.) A. Bone marrow hypoplasia B. Chemical exposure C. Down syndrome D. Ionizing radiation E. Multiple blood transfusions F. Prematurity at birth
A, B, C, D Reduced production of blood cells in the bone marrow is one of the risk factors for developing leukemia. Exposure to chemicals through medical need or by environmental events can also contribute. Certain genetic factors contribute to the development of leukemia; Down syndrome is one such condition. Radiation therapy for cancer or other exposure to radiation, perhaps through the environment, also contributes. There is no indication that multiple blood transfusions are connected to clients who have leukemia. Although some genetic factors may influence the incidence of leukemia, prematurity at birth is not one of them.
The nurse is teaching a client about induction therapy for acute leukemia. Which client statement indicates a need for additional education? A. "After this therapy, I will not need to have any more." B. "I will need to avoid people with a cold or flu." C. "I will probably lose my hair during this therapy." D. "The goal of this therapy is to put me in remission."
A. "After this therapy, I will not need to have any more." Induction therapy is not a cure for leukemia, it is a treatment; therefore, the client needs more education to understand this. Because of infection risk, clients with leukemia should avoid people with a cold or flu. Induction therapy will most likely cause the client with leukemia to lose his or her hair. The goal of induction therapy is to force leukemia into remission.
A 56-year-old client admitted with a diagnosis of acute myelogenous leukemia is prescribed IV cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. What is the major side effect of this therapy? A. Bone marrow suppression B. Liver toxicity C. Nausea D. Stomatitis
A. Bone marrow suppression Intravenous cytosine arabinoside and daunorubicin are a commonly prescribed course of aggressive chemotherapy, and bone marrow suppression is a major side effect. The client is even more at risk for infection than before treatment began. Liver toxicity, nausea, and stomatitis are not the major problems with this therapy.
The nurse is teaching a client with vitamin B12 deficiency anemia about dietary intake. Which type of food does the nurse encourage the client to eat? A. Dairy products B. Grains C. Leafy vegetables D. Starchy vegetables
A. Dairy products Dairy products such as milk, cheese, and eggs will provide the vitamin B12 that the client needs. Grains, leafy vegetables, and starchy vegetables are not a source of vitamin B12.
The nurse is assessing a newly admitted client with thrombocytopenia. Which factor needs immediate intervention? A. Nosebleed B. Reports of pain C. Decreased urine output D. Increased temperature
A. Nosebleed The client with thrombocytopenia has a high risk for bleeding. The nosebleed should be attended to immediately. The client's report of pain, decreased urine output, and increased temperature are not the highest priority.
The nurse assesses multiple clients who are receiving transfusions of blood components. Which assessment indicates the need for the nurse's immediate action? A. A partial thromboplastin time (PTT) that is 1.2 times normal in a client who received a transfusion of fresh-frozen plasma (FFP) B. Respiratory rate of 36 breaths/min in a client receiving red blood cells C. Sleepiness in a client who received diphenhydramine (Benadryl) as a premedication D. Temperature of 99.1° F (37.3° C) for a client with a platelet transfusion
B. Respiratory rate of 36 breaths/min in a client receiving red blood cells An increased respiratory rate indicates a possible hemolytic transfusion reaction; the nurse should quickly stop the transfusion and assess the client further. Because FFP is not usually given until the PTT is 1.5 times above normal, a PTT that is 1.2 times normal indicates that the FFP has had the desired response. Sleepiness is expected when Benadryl is administered. Temperature elevations are not an indication of an allergic reaction to a platelet transfusion, although the nurse may administer acetaminophen (Tylenol) to decrease the fever.
An 82-year-old client with anemia is requested to receive 2 units of whole blood. Which assessment findings cause the nurse to discontinue the transfusion because it is unsafe for the client? (Select all that apply.) A. Capillary refill less than 3 seconds B. Decreased pallor C. Flattened superficial veins D. Hypertension E. Hypotension F. Rapid, bounding pulse
D, E, F In an older adult receiving a transfusion, hypertension is a sign of overload, low blood pressure is a sign of a transfusion reaction, and a rapid and bounding pulse is a sign of fluid overload. In this scenario, 2 units, or about a liter of fluid, could be problematic. Capillary refill time that is less than 3 seconds is considered to be normal and would not pose a problem. Increased (not decreased) pallor and cyanosis are signs of a transfusion reaction, while swollen (not flattened) superficial veins are present in fluid overload in older adult clients receiving transfusions.
A client with thrombocytopenia is being discharged. What information does the nurse incorporate into the teaching plan for this client? A. "Avoid large crowds." B. "Drink at least 2 liters of fluid per day." C. "Elevate your lower extremities when sitting." D. "Use a soft-bristled toothbrush."
D. "Use a soft-bristled toothbrush." Using a soft-bristled toothbrush reduces the risk for bleeding in the client with thrombocytopenia. Avoiding large crowds reduces the risk for infection, but is not specific to the client with thrombocytopenia. Increased fluid intake reduces the risk for dehydration, but is not specific to the client with thrombocytopenia. Elevating extremities reduces the risk for dependent edema, but is not specific to the client with thrombocytopenia.
The nurse is transfusing a unit of whole blood to a client when the health care provider requests the following: "Furosemide (Lasix) 20 mg IV push." What does the nurse do? A. Add furosemide to the normal saline that is infusing with the blood. B. Administer furosemide to the client intramuscularly (IM). C. Piggyback furosemide into the infusing blood. D. Wait until the transfusion has been completed to administer furosemide.
D. Wait until the transfusion has been completed to administer furosemide. Completing the transfusion before administering furosemide is the best course of action in this scenario. Drugs are not to be administered with infusing blood products; they can interact with the blood, causing risks for the client. Stopping the infusing blood to administer the drug and then restarting it is also not the best decision. Changing the admission route is not a nursing decision.
A distant family member arrives to visit a female client recently diagnosed with leukemia. The family member asks the nurse, "What should I say to her?" Which responses does the nurse suggest? (Select all that apply.) A. "Ask her how she is feeling." B. "Ask her if she needs anything." C. "Tell her to be brave and to not cry." D. "Talk to her as you normally would when you haven't seen her for a long time." E. "Tell her what you know about leukemia."
A, B, D Asking the client how she is feeling is a broad general opening and would be nonthreatening to the client. Asking if she needs anything is a therapeutic communication of offering self and would be considered to be therapeutic and helpful to the client. The family member should talk to her as she normally would when she hasn't seen her in a long time. There is no need to act differently with the client. If she wants to offer her feelings, keeping a normal atmosphere facilitates that option. Acting as if things are "different" because she has cancer takes the control of the situation from the client. Telling her to be brave and not to cry is callous and unfeeling; if the client is feeling vulnerable and depressed, telling her to "be brave" shuts off any opportunity for her to express her feelings. There is no need to inform the client about her disease, unless she asks about it. Opening the conversation with discussion about leukemia should be the client's prerogative.
The nurse is teaching a client with newly diagnosed anemia about conserving energy. What does the nurse tell the client? (Select all that apply.) A. "Allow others to perform your care during periods of extreme fatigue." B. "Drink small quantities of protein shakes and nutritional supplements daily." C. "Perform a complete bath daily to reduce your chance of getting an infection." D. "Provide yourself with four to six small, easy-to-eat meals daily." E. "Perform your care activities in groups to conserve your energy." F. "Stop activity when shortness of breath or palpitations are present."
A, B, D, F It is critical to have others help the anemic client who is extremely tired. Although it may be difficult for him or her to ask for help, this practice should be stressed to the client. Drinking small protein or nutritional supplements will help rebuild the client's nutritional status. Having four to six small meals daily is preferred over three large meals; this practice conserves the body's expenditure of energy used in digestion and assimilation of nutrients. Stopping activities when strain on the cardiac or respiratory system is noted is critical. A complete bath should be performed only every other day; on days in between, the client can be taught to take a "mini" sponge bath, which will conserve energy and still be safe in preventing the risks for infection. Care activities should be spaced every hour or so rather than in groups to conserve energy; the time just before and after meals should be avoided.
Which client is at greatest risk for having a hemolytic transfusion reaction? A. A 34-year-old client with type O blood B. A 42-year-old client with allergies C. A 58-year-old immune-suppressed client D. A 78-year-old client
A. A 34-year-old client with type O blood Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood that contains antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. Type O is considered the universal donor, but not the universal recipient. *The client with allergies would be most susceptible to an allergic transfusion reaction. The immune-suppressed client would be most susceptible to a transfusion-associated graft-versus-host disease. The older adult client would be most susceptible to circulatory overload.*
An RN from pediatrics has "floated" to the medical-surgical unit. Which client is assigned to the float nurse? A. A 42-year-old with sickle cell disease receiving a transfusion of packed red blood cells B. A 50-year-old with pancytopenia needing assessment of risk factors for aplastic anemia C. A 55-year-old with folic acid deficiency anemia caused by alcohol abuse who needs counseling D. A 60-year-old with newly diagnosed polycythemia vera who needs teaching about the disease
A. A 42-year-old with sickle cell disease receiving a transfusion of packed red blood cells Because sickle cell disease is commonly diagnosed during childhood, the pediatric nurse will be familiar with the disease and with red blood cell transfusion; therefore, he or she should be assigned to the client with sickle cell disease. Aplastic anemia, folic acid deficiency, and polycythemia vera are problems more commonly seen in adult clients who should be cared for by nurses who are more experienced in caring for adults.
The nurse is caring for a group of hospitalized clients. Which client is at greatest risk for infection and sepsis? A. An 18-year-old who had an emergency splenectomy B. A 22-year-old with recently diagnosed sickle cell anemia C. A 38-year-old with hemolytic anemia D. A 40-year-old alcoholic with liver disease
A. An 18-year-old who had an emergency splenectomy Removal of the spleen causes reduced immune function. Without a spleen, the client is less able to remove disease-causing organisms, and is at increased risk for infection. Sickle cell anemia causes pain and discomfort because of the changed cell morphology, so acute pain, especially at joints, is the greatest threat to this client. A low red blood cell count with hemolytic anemia 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, so 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? A. Applying pressure to the biopsy site B. Inspecting the site for ecchymoses C. Sending the biopsy specimens to the laboratory D. Teaching the client about avoiding vigorous activity
A. Applying pressure to the biopsy site The initial action should be to stop bleeding by applying pressure to the site. Inspecting for ecchymoses, sending specimens to the laboratory, and teaching the client about activity levels will be done after hemostasis has been achieved.
What are serious side effects of antiviral agents prescribed for a client with acute myelogenous leukemia? (Select all that apply.) A. Cardiomyopathy B. Nephrotoxicity C. Ototoxicity D. Stroke E. Diarrhea
B, C Antiviral agents, although helpful in combating severe infection, have serious side effects, especially nephrotoxicity and ototoxicity. Cardiomyopathy and stroke are not serious side effects of antiviral agents. Diarrhea is a mild side effect associated with antibiotic therapy.
What are the typical clinical manifestations of anemia? (Select all that apply.) A. Decreased breath sounds B. Dyspnea on exertion C. Elevated temperature D. Fatigue E. Pallor F. Tachycardia
B, D, E, F Difficulty breathing—especially with activity—is common with anemia. Lower levels of hemoglobin carry less O2 to the cells of the body. Fatigue is a classic symptom of anemia; lowered O2 levels contribute to a faster pulse (i.e., cardiac rate) and tend to "wear out" a client's energy. Lowered O2 levels deliver less oxygen to all cells, making clients with anemia pale—especially their ears, nail beds, palms, and conjunctivae and around the mouth. Respiratory problems with anemia do not include changes in breath sounds; dyspnea and decreased oxygen saturation levels are present. Skin is cool to the touch, and an intolerance to cold is noted; elevated temperature would signify something additional, such as infection.
The nurse is assessing the endurance level of a client in a long-term care facility. What question does the nurse ask to get this information? A. "Are your feet or hands cold, even when you are in bed?" B. "Do you feel more tired after you get up and go to the bathroom?" C. "How much exercise do you get?" D. "What is your endurance level?"
B. "Do you feel more tired after you get up and go to the bathroom?" Asking about feeling tired after using the bathroom is pertinent to the client's activity and provides a comparison. The specific activity helps the client relate to the question and provide needed answers. Asking about cold feet or hands does not address the client's endurance. The hospitalized client typically does not get much exercise; this would be a difficult assessment for a client in long-term care facility to make. Asking the client about his or her endurance level is too vague; the client may not know how to answer this question.
The nurse is assessing a client for hematologic function risks and 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? A. "Do you seem to have excessive bleeding or bruising?" B. "Does anyone in your family bleed a lot?" C. "Tell me what you eat in a day." D. "Where do you work?"
B. "Does anyone in your family bleed a lot?" 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. Diet can affect risk, but it is a health behavior that can be changed. Work habits can be a risk, such as working near radiation, but these are behaviors that can be changed.
The nurse is educating a group of young women who have sickle cell disease (SCD). Which comment from a class member requires correction? A. "Frequent handwashing is an important habit for me to develop." B. "Getting an annual 'flu shot' would be dangerous for me." C. "I must take my penicillin pills as prescribed, all the time." D. "The pneumonia vaccine is protection that I need."
B. "Getting an annual 'flu shot' would be dangerous for me." The client with SCD should receive annual influenza and pneumonia vaccinations; this helps prevent the development of these infections, which could cause a sickle cell crisis. Handwashing is a very important habit for the client with SCD to develop because it reduces the risk for infection. Prophylactic penicillin is given to clients with SCD orally twice a day to prevent the development of infection.
Which client statement indicates that stem cell transplantation that is scheduled to take place in his home is not a viable option? A. "I don't feel strong enough, but my wife said she would help." B. "I was a nurse, so I can take care of myself." C. "I will have lots of medicine to take." D. "We live 5 miles from the hospital."
B. "I was a nurse, so I can take care of myself." Stem cell transplantation in the home setting requires support, assistance, and coordination from others. The client cannot manage this type of care on his own. The client must be emotionally stable to be a candidate for this type of care. It is acceptable for the client's spouse to support the client undergoing this procedure. It is not unexpected for the client to be taking several prescriptions. Five miles is an acceptable distance from the hospital, in case of emergency.
A client with anemia asks the nurse, "Do most people have the same number of red blood cells?" How does the nurse respond? A. "No, they don't." B. "The number varies with gender, age, and general health." C. "Yes, they do." D. "You have fewer red blood cells because you have anemia."
B. "The number varies with gender, age, and general health." Telling the client that the number of red blood cells (RBCs) varies with gender, age, and general health is the most educational and reasonable response to the client's question. Although telling the client that people do not have the same number of RBCs is true, it is not informative, and there is a better answer. While it may be true that the client has fewer red blood cells because of anemia, it does not answer the client's general question.
The nurse is reinforcing information about genetic counseling to a client with sickle cell disease who has a healthy spouse. What information does the nurse include? A. "Sickle cell disease will be inherited by your children." B. "The sickle cell trait will be inherited by your children." C. "Your children will have the disease, but your grandchildren will not." D. "Your children will not have the disease, but your grandchildren could."
B. "The sickle cell trait will be inherited by your children." The children of the client with sickle cell disease will inherit the sickle cell trait, but may not inherit the disease. If both parents have the sickle cell trait, their children could get the disease.
The nurse is teaching a client about what to expect during a bone marrow biopsy. Which statement by the nurse accurately describes the procedure? A. "The doctor will place a small needle in your back and will withdraw some fluid." B. "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." C. "You will be alone because the procedure is sterile; we cannot allow additional people to contaminate the area." D. "You will be sedated, so you will not be aware of anything."
B. "You may experience a crunching sound or a scraping sensation as the needle punctures your bone." It is accurate to describe a crunching sound or scraping sensation. 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.
Which client does the nurse assign as a roommate for the client with aplastic anemia? A. A 23-year-old with sickle cell disease who has two draining leg ulcers B. A 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol) C. A 30-year-old with leukemia who is receiving induction chemotherapy D. A 34-year-old with idiopathic thrombocytopenia who is taking steroids
B. A 28-year-old with glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia who is receiving mannitol (Osmitrol) Because clients with aplastic anemia usually have low white blood cell counts that place them at high risk for infection, roommates such as the client with G6PD deficiency anemia should be free from infection or infection risk. The client with sickle cell disease has two draining leg ulcer infections that would threaten the diminished immune system of the client with aplastic anemia. The client with leukemia who is receiving induction chemotherapy and the client with idiopathic thrombocytopenia who is taking steroids are at risk for development of infection, which places the client with aplastic anemia at risk, too.
After reviewing the laboratory test results, the nurse calls the health care provider about which client? A. A 44-year-old receiving warfarin (Coumadin) with an international normalized ratio (INR) of 3.0 B. A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 C. A 49-year-old with hemophilia and a platelet count of 150,000/mm3 D. A 52-year-old who has had a hemorrhage with a reticulocyte count of 0.8%
B. A 46-year-old with a fever and a white blood cell (WBC) count of 1500/mm3 The client with a fever is neutropenic and is at risk for sepsis unless interventions such as medications to improve the WBC level and antibiotics are prescribed. The INR of 3.0 in the 44-year-old indicates a therapeutic warfarin level. A platelet count of 150,000/mm3 in the 49-year-old is normal. An elevated reticulocyte count in the 52-year-old is expected after hemorrhage.
Which intervention most effectively protects a client with thrombocytopenia? A. Avoiding the use of dentures B. Encouraging the use of an electric shaver C. Taking rectal temperatures D. Using warm compresses on trauma sites
B. Encouraging the use of an electric shaver The client with thrombocytopenia should be advised to use an electric shaver instead of a razor. Any small cuts or nicks can cause problems because of the prolonged clotting time. Dentures may be used by clients with thrombocytopenia as long as they fit properly and do not rub. To prevent rectal trauma, rectal thermometers should not be used. Oral or tympanic temperatures should be taken. Ice (not heat) should be applied to areas of trauma.
The nurse is caring for a client with sickle cell disease. Which action is most effective in reducing the potential for sepsis in this client? A. Administering prophylactic drug therapy B. Frequent and thorough handwashing C. Monitoring laboratory values to look for abnormalities D. Taking vital signs every 4 hours, day and night
B. Frequent and thorough handwashing Prevention and early detection strategies are used to protect the client in sickle cell crisis from infection. Frequent and thorough handwashing is of the utmost importance. Drug therapy is a major defense against infections that develop in the client with sickle cell disease, but is not the most effective way that the nurse can reduce the potential for sepsis. Continually assessing the client for infection and monitoring the daily complete blood count with differential white blood cell count is early detection, not prevention. Taking vital signs every 4 hours will help with early detection of infection, but is not prevention.
A newly admitted client has an elevated reticulocyte count. Which disorder does the nurse suspect in this client? A. Aplastic anemia B. Hemolytic anemia C. Infectious process D. Leukemia
B. Hemolytic anemia An elevated reticulocyte count in an 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 RBCs. 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. A low white blood cell count is expected in clients with leukemia.
A 32-year-old client is recovering from a sickle cell crisis. His discomfort is controlled with pain medications and he is to be discharged. What medication does the nurse expect to be prescribed for him before his discharge? A. Heparin (Heparin) B. Hydroxyurea (Droxia) C. Tissue plasminogen activator (t-PA) D. Warfarin (Coumadin)
B. Hydroxyurea (Droxia) Hydroxyurea (Droxia) has been used successfully to reduce sickling of cells and pain episodes associated with sickle cell disease (SCD). Clients with SCD are not prescribed anticoagulants such as heparin or warfarin (Coumadin). t-PA is used as a "clot buster" in clients who have had ischemic strokes.
The nurse is transfusing 2 units of packed red blood cells to a postoperative client. What post-transfusion electrolyte imbalance does the nurse want to rule out? A. Hypercalcemia B. Hyperkalemia C. Hypomagnesemia D. Hyponatremia
B. Hyperkalemia During transfusion, some cells are damaged. These cells release potassium, thus raising the client's serum potassium level (hyperkalemia). This complication is especially common with packed cells and whole-blood products. High serum calcium levels, low magnesium levels, or low sodium levels are not expected with blood transfusions.
A recently admitted client who is in sickle cell crisis requests "something for pain." What does the nurse administer? A. Intramuscular (IM) morphine sulfate B. Intravenous (IV) hydromorphone (Dilaudid) C. Oral ibuprofen (Motrin) D. Oral morphine sulfate (MS-Contin)
B. Intravenous (IV) hydromorphone (Dilaudid) The client needs IV pain relief, and it should be administered on a routine schedule (i.e., before the client has to request it). Morphine is not administered intramuscularly (IM) to clients with sickle cell disease (SCD). In fact, all IM injections are avoided because absorption is impaired by poor perfusion and sclerosed skin. Nonsteroidal anti-inflammatory drugs may be used for clients with SCD for pain relief once their pain is under control; however, in a crisis, this choice of analgesic is not strong enough. Moderate pain may be treated with oral opioids, but this client is in a sickle cell crisis; IV analgesics should be used until his or her condition stabilizes.
The 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? A. Hemoglobin level B. Platelet (thrombocyte) count C. Red blood cell (RBC) count D. White blood cell (WBC) response
B. Platelet (thrombocyte) count 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 RBC and 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.
A hematology unit is staffed by RNs, LPN/LVNs, and unlicensed assistive personnel (UAP). When the nurse manager is reviewing documentation of staff members, which entry indicates that the staff member needs education about his or her appropriate level of responsibility and client care? A. "Abdominal pain relieved by morphine 4 mg IV; client resting comfortably and denies problems. B.C., RN" B. "Ambulated in hallway for 40 feet and denies shortness of breath at rest or with ambulation. T.Y., LPN" C. "Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" D. "Vital signs 37.0° C, heart rate 60, respiratory rate 20, blood pressure 110/68, and oximetry 98% on room air. L.D., UAP"
C. "Client reporting increased shortness of breath; oxygen increased to 4 L by nasal cannula. M.N., UAP" Determination of the need for oxygen and administration of oxygen should be done by licensed nurses who have the education and scope of practice required to administer it. All other documentation entries reflect appropriate delegation and assignment of care.
The nurse is assessing an adult client's endurance in performing activities of daily living (ADLs). What question does the nurse ask the client? A. "Can you prepare your own meals?" B. "Has your weight changed by 5 pounds or more this year?" C. "How is your energy level compared with last year?" D. "What medications do you take daily, weekly, and monthly?"
C. "How is your energy level compared with last year?" Asking the client how his or her energy level compares with last year 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 for ADLs. The client may never have been able to prepare his or her own meals, and the ability to prepare meals does not really address endurance. The question about weight change addresses nutrition and metabolic needs, rather than ADL performance. The question about how often the client takes medication addresses nutrition and metabolic needs and focuses on health maintenance through the use of drugs, not on the client's ability to perform ADLs.
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? A. "It is to dissolve blood clots." B. "It might cause me to get injured more often." C. "It should prevent my blood from clotting." D. "It will thin my blood."
C. "It should prevent my blood from clotting." 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 dissolve clots, fibrinolytics do. Anticoagulants do not cause more injuries, but may cause more bleeding and bruising when the client is injured. Anticoagulants do not cause any change in the thickness or viscosity of the blood.
The 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? A. "Avoid contact sports or activity that may traumatize the site for 24 hours." B. "Inspect the site for bleeding every 4 to 6 hours." C. "Place an ice pack over the site to reduce the bruising." D. "Take a mild analgesic, such as two aspirin, for pain or discomfort at the site."
C. "Place an ice pack over the site to reduce the bruising." Ice to the site will help limit bruising and tissue damage during the first 24 hours after the procedure. Contact sports and traumatic activity must be excluded for 48 hours, or 2 days. The client should carefully monitor the site every 2 hours for the first 24 hours after 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? A. "Platelets make your blood clot." B. "Blood clotting is prevented by your platelets." C. "The clotting process begins with your platelets." D. "Your platelets finish the clotting process."
C. "The clotting process begins with your platelets." 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. Platelets do not prevent the blood from clotting; rather they function to help blood form clots. Platelets do not finish the clotting process, they begin it.
A client with leukemia is being discharged from the hospital. After hearing the nurse's instructions to keep regularly scheduled follow-up provider appointments, the client says, "I don't have transportation." How does the nurse respond? A. "A pharmaceutical company might be able to help." B. "I might be able to take you." C. "The local American Cancer Society may be able to help." D. "You can take the bus."
C. "The local American Cancer Society may be able to help." Many local units of the American Cancer Society offer free transportation to clients with cancer, including those with leukemia. Suggesting a pharmaceutical company is not the best answer; drug companies typically do not provide this type of service. Although the nurse offering to take the client is compassionate, it is not appropriate for the nurse to offer the client transportation. Telling the client to take the bus is dismissive and does not take into consideration the client's situation (e.g., the client may live nowhere near a bus route).
Which client does the medical unit charge nurse assign to an LPN/LVN? A. A 23-year-old scheduled for a bone marrow biopsy with conscious sedation B. A 35-year-old with a history of a splenectomy and a temperature of 100.9° F (38.3° C) C. A 48-year-old with chronic microcytic anemia associated with alcohol use D. A 62-year-old with atrial fibrillation and an international normalized ratio of 6.6
C. A 48-year-old with chronic microcytic anemia associated with alcohol use Chronic microcytic anemia is not considered life-threatening and can be assigned to an LPN/LVN. The clients with a bone marrow biopsy with conscious sedation, a history of splenectomy and a temperature, and atrial fibrillation require more complex assessment or nursing care and should be assigned to RN staff members.
A 56-year-old client admitted with a diagnosis of acute myelogenous leukemia (AML) is prescribed IV cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. An infection develops. What knowledge does the nurse use to determine that the appropriate antibiotic has been prescribed for this client? A. Evaluating the client's liver function tests (LFTs) and serum creatinine levels B. Evaluating the client's white blood cell (WBC) count level C. Checking the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection D. Recognizing that vancomycin (Vancocin) is the drug of choice used to treat all infections in clients with AML
C. Checking the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection Checking the culture and sensitivity test results to be certain that the requested antibiotic is effective against the organism causing the infection is the best action to take. Drug therapy is the main defense against infections that develop in clients undergoing therapy for AML. Agents used depend on the client's sensitivity to various antibiotics for the organism causing the infection. Although LFTs and kidney function tests may be influenced by antibiotics, these tests do not determine the effectiveness of the antibiotic. Although the WBC count is elevated in infection, this test does not influence which antibiotic will be effective in fighting the infection. Vancomycin may not be effective in all infections; culturing of the infection site and determining the organism's sensitivity to a cohort of drugs are needed, which will provide data on drugs that are capable of eradicating the infection in this client.
Which action does the nurse delegate to unlicensed assistive personnel (UAP) who are assisting with the care of a female client with anemia? A. Asking the client about the amount of blood loss with each menstrual period B. Checking for sternal tenderness while applying fingertip pressure C. Determining the respiratory rate before and after the client walks 20 feet D. Monitoring her oral mucosa for pallor, bleeding, or ulceration
C. Determining the respiratory rate before and after the client walks 20 feet Assessment of the 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, checking for sternal tenderness, and monitoring oral mucosa require skilled assessment techniques and knowledge of normal parameters and should be done by the RN.
The nurse is infusing platelets to a client who is scheduled for a hematopoietic stem cell transplant. What procedure does the nurse follow? A. Administer intravenous corticosteroids before starting the transfusion. B. Allow the platelets to stabilize at the client's bedside for 30 minutes. C. Infuse the transfusion over a 15- to 30-minute period. D. Set up the infusion with the standard transfusion Y tubing.
C. Infuse the transfusion over a 15- to 30-minute period. The volume of platelets—200 or 300 mL (standard amount)—needs to be infused rapidly over a 15- to 30-minute period. Administering steroids is not standard practice in administering platelets. Platelets must be administered immediately after they are received; they are considered to be quite fragile. A special transfusion set with a smaller filter and shorter tubing is used to get the platelets into the client quickly and efficiently.
The nurse is caring for a client with neutropenia who has a suspected infection. Which intervention does the nurse implement first? A. Hydrate the client with 1000 mL of IV normal saline. B. Initiate the administration of prescribed antibiotics. C. Obtain requested cultures. D. Place the client on Bleeding Precautions.
C. Obtain requested cultures. Obtaining cultures to identify the infectious agent correctly is the priority for this client. Hydrating the client is not the priority. Administering antibiotics is important, but antibiotics should always be started after cultures are obtained. Placing the client on Bleeding Precautions is unnecessary.
A 32-year-old client recovering from a sickle cell crisis is to be discharged. The nurse says, "You and all clients with sickle cell disease are at risk for infection because of your decreased spleen function. For this reason, you will most likely be prescribed an antibiotic before discharge." Which drug does the nurse anticipate the health care provider will request? A. Cefaclor (Ceclor) B. Gentamicin (Garamycin) C. Penicillin V (Pen-V K) D. Vancomycin (Vancocin)
C. Penicillin V (Pen-V K) Prophylactic therapy with twice-daily oral penicillin reduces the incidence of pneumonia and other streptococcal infections and is the correct drug to use. It is a standard protocol for long-term prophylactic use in clients with sickle cell disease. Cefaclor (Ceclor) and vancomycin (Vancocin) are antibiotics more specific for short-term use and would be inappropriate for this client. Gentamicin (Garamycin) is a drug that can cause liver and kidney damage with long-term use.
The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper client identification? A. Asks the client's name B. Checks the client's armband C. Reviews all information with another registered nurse D. Verifies the client's room number
C. Reviews all information with another registered nurse With another registered nurse, verify the client by name and number, check blood compatibility, and note expiration time. Human error is the most common cause of ABO incompatibility reactions, even for experienced nurses. Asking the client's name and checking the client's armband are not adequate for identifying the client before transfusion therapy. Using the room number to verify client identification is never appropriate.
A client with multiple myeloma reports bone pain that is unrelieved by analgesics. How does the nurse respond to this client's problem? A. "Ask your doctor to prescribe more medication." B. "It is too soon for additional medication to be given." C. "I'll turn on some soothing classical music for you." D. "Would you like to try some relaxation techniques?"
D. "Would you like to try some relaxation techniques?" Because most clients with multiple myeloma have local or generalized bone pain, analgesics and alternative approaches for pain management, such as relaxation techniques, are used for pain relief. This also offers the client a choice. Before prescribing additional medication, other avenues should be explored to relieve this client's pain. Even if it is too soon to give additional medication, telling that to the client is not helpful because it dismisses the client's pain concerns. Although music therapy can be helpful, this response does not give the client a choice.
A client with anemia asks, "Why am I feeling tired all the time?" How does the nurse respond? A. "How many hours are you sleeping at night?" B. "You are not getting enough iron." C. "You need to rest more when you are sick." D. "Your cells are delivering less oxygen than you need."
D. "Your cells are delivering less oxygen than you need." The single most common symptom of anemia is fatigue, which occurs because oxygen delivery to cells is less than is required to meet normal oxygen needs. Although assessment of sleep and rest is good, it does not address the cause related to the diagnosis. While it may be true that the client isn't getting enough iron, it does not relate to the client's fatigue. The statement about the client needing rest because of being sick is simply not true.
The nurse is starting the shift by making rounds. Which client does the nurse decide to assess first? A. A 42-year-old with anemia who is reporting shortness of breath when ambulating down the hallway B. A 47-year-old who recently had a Rumpel-Leede test and is requesting a nurse to "look at the bruises on my arm" C. A 52-year-old who has just had a bone marrow aspiration and is requesting pain medication D. A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism
D. A 59-year-old who has a nosebleed and is receiving heparin to treat a pulmonary embolism The client with the nosebleed may be experiencing the bleeding as a result of excessive anticoagulation and should be assessed for the severity of the situation first. The client with anemia and the client who had a Rumpel-Leede test are more stable, and can be assessed later. Making clients wait for pain medication is not desirable, but in this scenario, the client who is bleeding is the higher priority. The client waiting for pain medication should be next on the nurse's "to do" list.
The nurse assesses the client with which hematologic problem first? A. A 32-year-old with pernicious anemia who needs a vitamin B12 injection B. A 40-year-old with iron deficiency anemia who needs a Z-track iron injection C. A 67-year-old with acute myelocytic leukemia with petechiae on both legs D. An 81-year-old with thrombocytopenia and an increase in abdominal girth
D. An 81-year-old with thrombocytopenia and an increase in abdominal girth An increase in abdominal girth in a client with thrombocytopenia indicates possible hemorrhage; this warrants further assessment immediately. The 32-year-old with pernicious anemia, the 40-year-old with iron deficiency anemia, and the 67-year-old with acute myelocytic leukemia do not indicate any acute complications, so the nurse can assess them after assessing the client with thrombocytopenia.
The nurse is assessing the nutritional status of a client with anemia. How does the nurse obtain information about the client's diet? A. Asks the client to rate his or her diet on a scale of 1 (poor) to 10 (excellent) B. Determines who prepares the client's meals and plans an interview with him or her C. From a prepared list, finds out the client's food preferences D. Has the client write down everything he or she has eaten for the past week
D. Has the client write down everything he or she has eaten for the past week Having the client provide a list of items eaten in the past week 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 protein, vitamin, and mineral intake. Rating scales are good for subjective data collection about some conditions such as pain, but the subjectivity of a response such as this does not provide the nurse with specific data needed to assess a diet. Interviewing the food preparer is time-consuming and poses several problems, such as whether a number of people are preparing meals, or if the client goes "out" for meals. Determining food preferences from a prepared list provides information about what the client enjoys eating, not necessarily what the client has been eating; for instance, the client may like steak but may be unable to afford it.
A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which potential problem takes priority in the client's nursing care plan? A. Fluid overload (overhydration) B. Hemorrhage C. Hypoxia D. Infection
D. Infection The main objective in caring for a newly diagnosed client with leukemia is protection from infection. Fluid overload, hemorrhage, and hypoxia are not priority problems for the client with leukemia.
Which would be an appropriate task to delegate to unlicensed assistive personnel (UAP) working on a medical-surgical unit? A. Administering erythropoietin to a client with myelodysplastic syndrome B. Assessing skin integrity on an anemic client who fell during ambulation C. Assisting a client with folic acid deficiency in making diet choices D. Obtaining vital signs on a client receiving a blood transfusion
D. Obtaining vital signs on a client receiving a blood transfusion Obtaining vital signs on a client is within the scope of practice for UAP. Administering medication, assessing clients, and assisting with prescribed diet choices are complex actions that should be done by licensed nurses.
The nurse is caring for a client who is in sickle cell crisis. What action does the nurse perform first? A. Apply cool compresses to the client's forehead. B. Encourage the client's use of two methods of birth control. C. Increase food sources of iron in the client's diet. D. Provide pain medications as needed.
D. Provide pain medications as needed. Analgesics are needed to treat sickle cell pain. Warm soaks or compresses can help reduce pain perception. Cool compresses do not help the client in sickle cell crisis. Birth control is not the priority for this client. Increasing iron in the diet is not pertinent for the client in sickle cell crisis.
Which action does the nurse delegate to unlicensed assistive personnel (UAP)? A. Drawing a partial thromboplastin time from a saline lock on a client with a pulmonary embolism B. Performing a capillary fragility test to check vascular hemostatic function on a client with liver failure C. Referring a client with a daily alcohol consumption of 12 beers for counseling D. Reporting any bleeding noted when catheter care is given to a client with a history of hemophilia
D. Reporting any bleeding noted when catheter care is given to a client with a history of hemophilia Reporting findings during routine care is expected and required of unlicensed staff members. Drawing a partial thromboplastin time, performing a capillary fragility test, and referring a client for alcohol counseling are more complex and should be done by licensed nursing staff.
What is the most important environmental risk for developing leukemia? A. Direct contact with others with leukemia B. Family history C. Living near high-voltage power lines D. Smoking cigarettes
D. Smoking cigarettes According to the American Cancer Society (ACS), the only proven lifestyle-related risk factor for leukemia is cigarette smoking. Leukemia is not contagious. Genetics is a strong indicator, but it is not an environmental risk factor. According to the ACS, living near high-voltage power lines is not a proven risk factor for leukemia.
A client who is receiving a blood transfusion suddenly exclaims to the nurse, "I don't feel right!" What does the nurse do next? A. Call the Rapid Response Team. B. Obtain vital signs and continue to monitor. C. Slow the infusion rate of the transfusion. D. Stop the transfusion.
D. Stop the transfusion. The client may be experiencing a transfusion reaction; the nurse should stop the transfusion immediately. Calling the Rapid Response Team or obtaining vital signs is not the first thing that should be done. The nurse should not slow the infusion rate, but should stop it altogether.
A client is scheduled for a bone marrow aspiration. What does the nurse do before taking the client to the treatment room for the biopsy? A. Clean the biopsy site with an antiseptic or povidone-iodine (Betadine). B. Hold the client's hand and ask about concerns. C. Review the client's platelet (thrombocyte) count. D. Verify that the client has given informed consent.
D. Verify that the client has given informed consent. 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 this is not done until consent is verified; it will be done just before the procedure is performed. Holding the client's hand and offering verbal support may be done during the procedure, but the procedure cannot be completed until the consent is signed. Reviewing the client's platelet count is not imperative.
The nurse is mentoring a recent graduate RN about administering blood and blood products. What does the nurse include in the data? A. Obtain the client's initial set of vital signs (VS) within the first 10 minutes of the infusion. B. Remain with the client who is receiving the blood for the first 5 minutes of the infusion. C. Use a 22-gauge needle to obtain venous access when starting the infusion. D. Verify with another RN all of the data on blood products.
D. Verify with another RN all of the data on blood products. All data are checked by two RNs. Human error is the most common cause of ABO incompatibilities in administering blood and blood products. Initial VS should be recorded before the start of infusion of blood, not after it has begun. The nurse remains with the client for the first 15 to 30 minutes (not 5) of the infusion. This is the period when any transfusion reactions are likely to happen. A 20-gauge needle (or a central line catheter) is used; the 22-gauge needle is too small.
The nurse is caring for a client with neutropenia. Which clinical manifestation indicates that an infection is present or should be ruled out? A. Coughing and deep breathing B. Evidence of pus C. Fever of 102° F or higher D. Wheezes or crackles
D. Wheezes or crackles Wheezes or crackles in the neutropenic client may be the first symptom of infection in the lungs. Coughing and deep breathing are not indications of infection, but can help prevent it. The client with leukopenia, not neutropenia, may have a severe infection without pus or with only a low-grade fever.
