Lewis Ch 29 Assessment of Hematologic System

Malignant disorders that arise from granulocytic cells in the bone marrow will have the primary effect of causing

Decreased phagocytosis of bacteria

An individual who lives at a high altitude may normally have an increased Hgb and RBC because

Hypoxia caused by decreased atmospheric oxygen stimulates erythropoiesis

Number the components of normal hemostasis in the order of occurrence, beginning with 1 for first component and ending with 6 for last. Adhesion (2nd) Activation (3rd) Aggregation (4th) Platelet plug formation(5th) Clot retraction and dissolution (6th) Vascular injury and subendothelial exposure (1st)

1. Vascular injury and subendothelial exposure 2. Adhesion 3. Activation 4. Aggregation 5. Platelet plug formation 6. Clot retraction and dissolution

What are the characteristics of neutrophils? (Select all that apply). a. Known as "segs" b. Band is immature cell c. First WBC at injury site d. Arises from megakaryocyte e. Increased in individuals with allergies f. 50-70% of WBCs

ANS: A, B, C, F a. Known as "segs" b. Band is immature cell c. First WBC at injury site f. 50-70% of WBCs These characteristics are evident with neutrophils. Platelets arise from megakaryocytes and are stored in the spleen. Eosinophils are increased in individuals with allergies and make up 0% to 4% of WBCs.

A pt with a bone marrow disorder has an overproduction of myeloblasts. The nurse would expect the results of a CBC to include an increase in which cell types? (Select all that apply). a. Basophils b. Eosinophils c. Monocytes d. Neutorphils e. Lymphocytes

ANS: A, B, D a. Basophils b. Eosinophils d. Neutorphils The myeloblast is a committed hematopoietic cell found in the bone marrow from which granulocyes develop. A disorder in which myeloblast are overproduced would result in increased basophils, eosinophils, and neutrophils.

Which nutrients are essential for RBC production? (Select all that apply). a. Iron b. Folic acid c. Vitamin C d. Vitamin D e. Vitamin b12 f. Carbohydrates

ANS: A, B, E a. Iron b. Folic acid e. Vitamin b12 Although all the listed nutrients are helpful, iron, folic acid, and cobalamin (Vitamin B12) are essential for erythropoiesis.

A patient who was in a car accident had abdominal trauma. Which organs may be damaged and contribute to altered function of the hematologic system? (Select all that apply). a. Liver b. Spleen c. Stomach d. Gallbladder e. Lymph nodes

ANS: A, B, E a. Liver b. Spleen e. Lymph nodes The abdominal organs that are primarily involved in hematoligic function are the liver, spleen, and lymph nodes. The liver filters the blood, produces procoagulants, and stores iron. The spleen's functions are hematopoietic (RBCs produced during fetal development); filtration (removes old and defective erythroctes, iron for reuse, and bacteria); immunologic (supplies lymphocytes, monocytes, and stored immunoglobulins); and storage (RBCs and platelets). The lymph nodes filter pathogens and foreign particles from lymphatic circulation.

Nursing care of a pt immediately after a bone marrow biopsy and aspiration includes (Select all that apply). a. Administering analgesics as neccessary b. Preparing to administer blood transfusion c. Instructing on the need to lie still with a sterile pressure dressing intact d. Monitoring VS and assessing the site for excess drainage or bleeding e. Instructing on the need for preprocedure and postprocedure antibiotic medications

ANS: A, C, D a. Administering analgesics as neccessary c. Instructing on the need to lie still with a sterile pressure dressing intact d. Monitoring VS and assessing the site for excess drainage or bleeding

Which cells are classified as granulocytes? (Select all that apply). a. Basophil b. Monocyte c. Eosinophil d. Neutrophil e. Lymphocyte f. Thrombocyte

ANS: A, C, D a. Basophil c. Eosinophil d. Neutrophil Basophils, eosinophils, and neutrophils are the granulocytic leukocytes. Lymphocytes are the agranular leukocytes that form the basis of the cellular and humoral immune responses. Monocytes are agranulocytes that are potent phagocytic cells. Thrombocytes are not granulocytes or agranulocytes, and they initiate the clotting process.

The nurse examines the lymph nodes of a patient during a physical assessment. Which assessment finding would be of most concern to the nurse? a. A 2-cm nontender supraclavicular node b. A 1-cm mobile and nontender axillary node c. An inability to palpate any superficial lymph nodes d. Firm inguinal nodes in a patient with an infected foot

ANS: A. A 2-cm nontender supraclavicular node Enlarged and nontender nodes are suggestive of malignancies such as lymphoma. Firm nodes are an expected finding in an area of infection. The superficial lymph nodes are usually not palpable in adults, but if they are palpable, they are normally 0.5 to 1 cm and nontender.

The complete blood count (CBC) indicates that a patient is thrombocytopenic. Which action should the nurse include in the plan of care? a. Avoid intramuscular injections. b. Encourage increased oral fluids. c. Check temperature every 4 hours. d. Increase intake of iron-rich foods.

ANS: A. Avoid intramuscular injections. Thrombocytopenia is a decreased number of platelets, which places the patient at high risk for bleeding. Neutropenic patients are at high risk for infection and sepsis and should be monitored frequently for signs of infection. Encouraging fluid intake and iron-rich food intake is not indicated in a patient with thrombocytopenia.

A patient with pancytopenia of unknown origin is scheduled for the following diagnostic tests. The nurse will provide a consent form to sign for which test? a. Bone marrow biopsy b. Abdominal ultrasound c. Complete blood count (CBC) d. Activated partial thromboplastin time (aPTT)

ANS: A. Bone marrow biopsy A bone marrow biopsy is a minor surgical procedure that requires the patient or guardian to sign a surgical consent form. The other procedures do not require a signed consent.

A patient is undergoing a contrast CT scan of the spleen. What is MOST important for the nurse to ask the patient about before the test? a. Iodine sensitivity b. Prior blood transfusions c. Phobia of confined spaces d. Internal metal implants or appliances

ANS: A. Iodine sensitivity A contrast CT scan involves the use of an iodine-based dye that could cause a reaction if the patient is sensitive to iodine. Metal implants or internal appliances and claustrophobia should be determined before MRI. Prior blood transfusions are not a factor in this diagnostic test.

Significant information obtained from the patients H&H that r/t the hematologic system includes a. Jaundice b. Bladder surgery c. Early menopause d. Multiple pregnancies

ANS: A. Jaundice

After a woman had a right breast mastectomy, her right arm became very swollen. What hematologic problem caused this? a. Lymphedema b. Right sided heart failure c. Wound on her right hand d. Refusal to use her right arm

ANS: A. Lymphedema Lymphedema is the obstruction of lymph flow that results in accumulation of lymph fluid for the patient in the right arm following a right-sided breast mastectomy. The other options are not hematologic problems that would cause extreme swelling.

Using light pressure with the index and middle fingers, the RN cannot palpate any of the pts superficial lymph nodes. How should the RN respond to this assessment? a. Record finding as normal b. Reassess lymph nodes using deeper pressure c. Ask the pt about any hx of radiation therapy d. Notify HCP that xrays will be neccessary

ANS: A. Record finding as normal Superficial lymph nodes are evaluated by light palpation, but they are not normally palpable. It may be normal to find small (<1cm), mobile, firm, non-tender nodes. Deep lymph nodes are detected radiographically.

During the assessment of a pt with anemia, what specific information should the RN ask the pt about? a. Stomach surgery b. Recurring infections c. Corticosteroid therapy d. Oral contraceptive use

ANS: A. Stomach surgery The parietal cells of the stomach secrete intrinsic factor, a substance necessary for the absorption of cobalamin (Vitamin B12), and if all or part of the stomach is removed, the lack of intrinsic factor can lead to imparied RBC production and pernicious anemia. Recurring infections indicate decreased WBCs and immune response, and corticosteriod therapy may cause a neutrophilia and lymphopenia. Oral contraceptive use is strongly associated with changes in blood coagulation.

Molecular cytogenis and gene analysis may be done to diagnose, stage, and help to determine tx options for various hematologic disorders. Which sites are preferred to obtain the sample for this testing? (Select all that apply). a. Skin sample b. Lymph node c. Bone marrow d. Arterial blood e. Inner cheek mucosa

ANS: B, C b. Lymph node c. Bone marrow Bone marrow and lymph node biopsies are preferred methods to obtain the sample for gene analysis. If a large number of abnormal cells are circulating in the blood, peripheral blood may be used. The other options will not provide the desired information.

A patient's complete blood count (CBC) shows a hemoglobin of 19 g/dL and a hematocrit of 54%. Which question should the nurse ask to determine possible causes of this finding? a. "Have you had a recent weight loss?" b. "Do you have any history of lung disease?" c. "Have you noticed any dark or bloody stools?" d. "What is your dietary intake of meats and protein?"

ANS: B. "Do you have any history of lung disease?" The hemoglobin and hematocrit results indicate polycythemia, which can be associated with chronic obstructive pulmonary disease. The other questions would be appropriate for patients who are anemic.

Laboratory test results indicated increased fibrin split products. An appropriate nursing action is to monitor the patient for: a. Fever b. Bleeding c. Faintness d. Thrombotic episodes

ANS: B. Bleeding During fibrinolysis by plasmin, the fibrin clot is split into smaller molecules known as FSPs or FDPs. Increased FSPs impair platelet aggregation, reduce prothrombin, prevent fibrin stabilization, and lead to bleeding.

A patient with pancytopenia has a bone marrow aspiration from the left posterior iliac crest. Which action would be important for the nurse to take after the procedure? a. Elevate the head of the bed to 45 degrees. b. Have the patient lie on the left side for 1 hour. c. Apply a sterile 2-inch gauze dressing to the site. d. Use a half-inch sterile gauze to pack the wound.

ANS: B. Have the patient lie on the left side for 1 hour. To decrease the risk for bleeding, the patient should lie on the left side for 30 to 60 minutes. After a bone marrow biopsy, the wound is small and will not be packed with gauze. A pressure dressing is used to cover the aspiration site. There is no indication to elevate the patient's head.

The nurse is reviewing laboratory results and notes a patient's activated partial thromboplastin time (aPTT) level of 28 seconds. The nurse should notify the health care provider in anticipation of adjusting which medication? a. Aspirin b. Heparin c. Warfarin d. Erythropoietin

ANS: B. Heparin aPTT assesses intrinsic coagulation by measuring factors I, II, V, VIII, IX, X, XI, XII. aPTT is increased (prolonged) in heparin administration. aPTT is used to monitor whether heparin is at a therapeutic level (needs to be greater than the normal range of 25 to 35 sec). Prothrombin time (PT) and international normalized ratio (INR) are most commonly used to test for therapeutic levels of warfarin (Coumadin). Aspirin affects platelet function. Erythropoietin is used to stimulate red blood cell production.

A pt with a hematologic disorder has a smooth, shiny, red tongue. Which lab result would the nurse expect to see? a. Neutrophils 45% b. Hgb 9.6 g/dL c. WBC count 13,500/uL d. RBC count 6.4 x 10^6/uL

ANS: B. Hgb 9.6 g/dL A smooth, shiny, reddened tongue is an indication of iron-deficiency anemia or pernicious anemia that would be reflected by a decreased hemoglobin level. The decreased neutrophils would be indicative of neutropenia. The increased WBC count could be indicative of an infection and the increased RBC count of polycythemia.

During physical assessment of a pt with thrombocytopenia, what would the RN expect to find? a. Sternal tenderness b. Petechiae and purpura c. Jaundiced sclera and skin d. Tender, enlarged lymph nodes

ANS: B. Petechiae and purpura Petechiae are small, flat, red, or reddish-brown pinpoint microhemorrhages that occur on the skin when platelet levels are low. When petechiae are numerous, they group, cause reddish bruises known as purpura. Sternal tenderness is associated with leukemias. Jaundice occurs when anemia are of a hemolytic origin, resulting in accumulation of bile pigments from RBCs. Enlarged, tender lymph nodes are associated with infection or cancer.

Which information shown in the table below about a patient who has just arrived in the emergency department is most urgent for the nurse to communicate to the health care provider? Assessment • BP 110/68 • Pulse 98 beats/min • Brisk capillary refill • Multiple ecchymoses on arms Complete Blood Count • Hgb 10.6 g/dL • Hct 30% • WBC 5100/µL • Platelets 19,500/µL Patient History • Occasional aspirin use • Abdominal pain x 1 week • Large, dark stool this morning a. Heart rate b. Platelet count c. Abdominal pain d. White blood cell count

ANS: B. Platelet count The platelet count is severely decreased and places the patient at risk for spontaneous bleeding. The other information is also pertinent but not as indicative of the need for rapid treatment as the platelet count.

If a patient with type O Rh+ is given AB Rh- blood, what would the nurse expect to happen? a. The patient's Rh factor will react with the RBCs of the donor blood. b. The anti-A and anti-B antibodies in the patient's blood will hemolyze the donor blood. c. The patient will experience a brief, very sharp pain during aspiration of the bone marrow. d. There will be no pain during the procedure, but an ache will be present several days afterwards.

ANS: B. The anti-A and anti-B antibodies in pts blood will hemolyze the donor blood A patient with type O Rh+ blood has no A or B antigens on the RBC, but does have anti-A and anti-B antibodies in the blood and has an Rh antigen. Type AB Rh- blood has both A and B antigens on the RBC, but no Rh antigen and no anti-A or anti-B antibodies. If the type AB Rh- blood is given to the patient with type O Rh+ blood, the antibodies in the patient's blood will react with the antigens in the donor blood, causing hemolysis of the donor cells. There will be no Rh reaction because the donor blood has no Rh antigen.

The nurse assesses a patient who has numerous petechiae on both arms. Which question should the nurse ask the patient? a. "Are you taking any oral contraceptives?" b. "Have you been prescribed antiseizure drugs?" c. "Do you take medication containing salicylates?" d. "How long have you taken antihypertensive drugs?"

ANS: C. "Do you take medication containing salicylates?" Salicylates interfere with platelet function and can lead to petechiae and ecchymoses. Antiseizure drugs may cause anemia but not clotting disorders or bleeding. Oral contraceptives increase a person's clotting risk. Antihypertensives do not usually cause problems with decreased clotting.

A patient who had a total hip replacement had an intraoperative hemorrhage 14 hours ago. Which laboratory test result would the nurse expect? a. Hematocrit of 46% b. Hemoglobin of 13.8 g/dL c. Elevated reticulocyte count d. Decreased white blood cell (WBC) count

ANS: C. Elevated reticulocyte count Hemorrhage causes the release of reticulocytes (immature red blood cells) from the bone marrow into circulation. The hematocrit and hemoglobin levels are normal. The WBC count is not affected by bleeding.

The health care provider's progress note for a patient states that the complete blood count (CBC) shows a "shift to the left." Which assessment finding will the nurse expect? a. Cool extremities b. Pallor and weakness c. Elevated temperature d. Low oxygen saturation

ANS: C. Elevated temperature The term "shift to the left" indicates that the number of immature polymorphonuclear neutrophils (bands) is elevated and that finding is a sign of infection. There is no indication that the patient is at risk for hypoxemia, pallor or weakness, or cool extremities.

The nurse notes pallor of the skin and nail beds in a newly admitted patient. The nurse should ensure that which laboratory test has been ordered? a. Platelet count b. Neutrophil count c. Hemoglobin level d. White blood cell count

ANS: C. Hemoglobin level Pallor of the skin or nail beds is indicative of anemia, which would be indicated by a low Hgb level. Platelet counts indicate a person's clotting ability. A neutrophil is a type of white blood cell that helps to fight infection.

The nurse assesses a patient with pernicious anemia. Which assessment finding would the nurse expect? a. Yellow-tinged sclerae b. Shiny, smooth tongue c. Numbness of the extremities d. Gum bleeding and tenderness

ANS: C. Numbness of the extremities Extremity numbness is associated with cobalamin (vitamin B12) deficiency or pernicious anemia. Loss of the papillae of the tongue occurs with chronic iron deficiency. Yellow-tinged sclera is associated with hemolytic anemia and the resulting jaundice. Gum bleeding and tenderness occur with thrombocytopenia or neutropenia.

The pt's lab results show a marked decrease in RBCs, WBCs, and platelets. What term should the RN use when reporting the results to HCP? a. Hemolysis b. Leukopenia c. Pancytopenia d. Thrombocytosis

ANS: C. Pancytopenia Pancytopenia is decreased RBCs, WBCs, and platelets. Hemolysis is RBC destruction. Leukopenia is WBC <4,000/ul. Thrombocytosis is increased platelets, and thrombocytopenia is decreased platelets.

When reviewing the results of an 83 y/o pt.'s diagnostic studies, which finding would be of the MOST concern to the nurse? a. Platelets 150,000/uL b. Serum iron 50 mcg/dL c. Partial thromboplastin time 60 seconds d. ESR 35 mm in 1 hour

ANS: C. Partial thromboplastin time 60 seconds As a person ages the partial thromboplastin time (PTT) is normally decreased, so an abnormally high PTT of 60 seconds is an indication that bleeding could readily occur. Platelets are unaffected by aging and 150,000/ul is a normal count. Serum iron levels are decreased and the erythrocyte sedimentation rate (ESR) is significantly increased with aging, as are reflected in these values.

A patient is being treated with chemotherapy. The nurse revises the pt's care plan based on which result? a. WBC count 4000/uL b. RBC count 4.3x10^6/uL c. Platelets 50,000/uL d. Hematocrit 39%

ANS: C. Platelets 50,000/uL Any platelet count <150,000/ul is considered thrombocytopenia and could place the patient at risk for bleeding, necessitating special consideration in nursing care. Chemotherapy may cause bone marrow suppression and a depletion of all blood cells. The other factors are all within normal range.

An increase in which blood cell indicates an increased rate of erythropoiesis? a. Basophil b. Monocyte c. Reticulocyte d. Lymphocyte

ANS: C. Reticulocyte Increased reticulocytes, or immature RBCs, indicate an increased rate of erythropoiesis or stimulation of erythrocyte (RBC) production by the bone marrow. Basophils are stimulated by granulocyte colony-stimulating factor in response to an antigen or by tissue injury. Monocytes and lymphocytes respond to tissue injury, including infection.

When teaching a pt about bone marrow examination, what should the nurse explain? a. The procedure will be done under general anesthesia because it is so painful. b. The patient will not have any pain after the area at the puncture site is anesthetized. c. The patient will experience a brief, very sharp pain during aspiration of the bone marrow. d. There will be no pain during the procedure, but an ache will be present several days afterwards.

ANS: C. The pt will experience a brief very sharp pain during aspiration of the bone marrow The aspiration of bone marrow content is done with local anesthesia at the site of the puncture, but the aspiration causes a suction pain that is quite painful, but very brief. There generally is only residual soreness following the test.

The health care provider orders a liver and spleen scan for a patient who has been in a motor vehicle crash. Which action should the nurse take before this procedure? a. Check for any iodine allergy. b. Insert a large-bore IV catheter. c. Administer prescribed sedatives. d. Assist the patient to a flat position.

ANS: D. Assist the patient to a flat position. During a liver and spleen scan, a radioactive isotope is injected IV, and images from the radioactive emission are used to evaluate the structure of the spleen and liver. An indwelling IV catheter and sedation are not needed. The patient is placed in a flat position before the scan.

Which component of normal hemostasis involves the proess of protein C and protein S and plasminogen? a. Activation b. Aggregation c. Platelet plug formation d. Clot retraction and dissolution

ANS: D. Clot retraction and dissolution Protein C and protein S are examples of anticoagulants that are involved in clot retraction and dissolution. Fibrinolysis also keeps blood in its fluid form by thrombin-activating conversion of plasminogen to plasmin. Plasmin attacks fibrin or fibrinogen and splits it into smaller elements known as fibrin split products (FSPs) or fibrin degradation products (FDPs).

A lymph node biopsy is most often performed to diagnose: a. Leukemia b. Cause of lymphedma c. Hemorrhagic tendencies d. Neoplastic cells in lymph nodes

ANS: D. Neoplastic cells in lymph nodes Lymph node biopsy is usually done to determine whether malignant cells are present in lymph nodes and can be used to diagnose lymphomas as well as metastatic spread from any malignant tumor in the body. Leukemias may infiltrate lymph nodes, but biopsy of the nodes is more commonly used to detect any type of neoplastic cells.

The nurse is caring for a patient who is being discharged after an emergency splenectomy following a motor vehicle crash. Which instructions should the nurse include in the discharge teaching? a. Check often for swollen lymph nodes. b. Watch for excess bleeding or bruising. c. Take iron supplements to prevent anemia. d. Wash hands and avoid persons who are ill.

ANS: D. Wash hands and avoid persons who are ill. Splenectomy increases the risk for infection, especially with gram-positive bacteria. The risks for lymphedema, bleeding, and anemia are not increased after a person has a splenectomy.

The nurse reviews the laboratory test results of a patient admitted with abdominal pain. Which information will be most important for the nurse to communicate to the health care provider? a. Monocytes 4% b. Hemoglobin 13.6 g/dL c. Platelet count 168,000/µL d. White blood cell (WBC) count 15,500/µL

ANS: D. White blood cell (WBC) count 15,500/µL The elevation in WBCs indicates that the patient has an inflammatory or infectious process ongoing, which may be the cause of the patient's pain, and that further diagnostic testing is needed. The monocytes are at a normal level. The hemoglobin and platelet counts are normal.

A nurse reviews the laboratory data for an older patient. The nurse would be most concerned about which finding? a. Hematocrit of 35% b. Hemoglobin of 11.8 g/dL c. Platelet count of 400,000/µL d. White blood cell (WBC) count of 2800/µL

ANS: D. White blood cell (WBC) count of 2800/µL Because the total WBC count is not usually affected by aging, the low WBC count in this patient would indicate that the patient's immune function may be compromised and the underlying cause of the problem needs to be investigated. The platelet count is normal. The slight decrease in hemoglobin and hematocrit are not unusual for an older patient.

An anticoagulant such as warfarin that interferes with prothrombin production will alter the mechanism during

Activation of thrombin

If a lymph node is palpated, what is a normal finding?

Firm, mobile nodes

While assessing the lymph nodes, the RN should

Lightly palpate superficial lymph nodes with the pads of fingers

When reviewing lab results of an older patient with an infection, the nurse would expect to find

Minimal leukocytosis

Laboratory Findings and their possible Etiology 1. Serum iron 40 mcg/dl (7umol/L) - Iron-deficiency anemia 2. ESR 30mm/hr - Inflammatory conditions of any kind 3. Increased band neutrophils - Infection 4. Activated PTT 60 sec - Heparin therapy 5. Indirect bilirubin 2.0mg/dl (34 umol/dL) - Hemolysis of RBCs 6. Bence Jones protein in urine - Multiple myeloma

Possible Etiology 1. Iron-deficiency anemia 2. Inflammatory conditions of any kind 3. Infection 4. Heparin therapy 5. Hemolysis of RBCs 6. Multiple myeloma

Functional Health Pattern 1. Health perception - health management 2. Nutritional-metabolic 3. Elimination 4. Activity - exercise 5. Sleep - rest 6. Cognitive - perceptual 7. Self-perception - self-concept 8. Role - relationship 9. Sexuality - reproductive 10. Coping - stress tolerance 11. Value - belief

Risk Factor / Response to Hematologic Problem 1. Ethic background, family hx of hematologic disorders. Use of alcohol, illicit drugs, and cigs. 2. Weight. Hx of anorexia, N/V, or oral discomfort. Deficiencies of iron, vit B12, and folic acid. GI bleeding, petechiae or bruising of the skin, fever, lymph node swelling. 3. Frankly bloody or dark, tarry stools, dark or bloody urine. 4. Fatigue, weakness, change in ability to perform normal exercise or ADLs. 5. Fatigue unrelieved by sleep. 6.Pain, esp in joints or bones. Paresthesias, numbness/tingling, Changes in hearing, vision, taste, or mental status. 7. Altered due to lymph node enlargement or skin changes. 8. Home or work exposure to radiation or chemical. Military hx; change in role or responsibility. 9. Menstrual hx and characteristics of bleeding. Intrapartum or postpartum bleeding problems. Impotence. 10. Lack of support to meet daily needs. Methods of coping with stress. 11. Values conflict with treatment, esp. blood product or bone marrow transplants.

You are taking care of a male patient who has the following lab values from his CBC: WBC 6.5x10^6/uL, Hgb 13.4 g/dL, Hct 40%, platelets 50 x 10^3/uL. What are you concerned about?

Your patient is at risk for bleeding