NCLEX Ch 32
Which of the following is the percentage of blood volume consisting of erythrocytes? a) Hematocrit b) Hemoglobin c) Erythrocyte sedimentation rate (ESR) d) Differentiation
a) Hematocrit Explanation: Hematocrit is the percentage of blood volume consisting of erythrocytes. Differentiation is development of functions and characteristics that are different from those of the parent stem cell. ESR is a lab test that measures the rate of settling of RBCs and elevation is indicative of inflammation. Hemoglobin is the iron-containing protein of RBCs.
Which of the following terms refers to a form of white blood cell involved in immune response? a) Spherocyte b) Lymphocyte c) Thrombocyte d) Granulocyte
b) Lymphocyte Explanation: Mature lymphocytes are the principal cells of the immune system, producing antibodies and identifying other cells and organisms as "foreign." Both B and T lymphocytes respond to exposure to antigens. Granulocytes include basophils, neutrophils, and eosinophils. A spherocyte is a red blood cell without central pallor, seen with hemolysis. A thrombocyte is a platelet.
Which type of lymphocyte is responsible for cellular immunity? a) B lymphocyte b) T lymphocyte c) Plasma cell d) Basophil
b) T lymphocyte Explanation: T lymphocytes are responsible for delayed allergic reactions, rejection of foreign tissue (e.g., transplanted organs), and destruction of tumor cells. This process is known as cellular immunity. B lymphocytes are responsible for humoral immunity. A plasma cell secretes immunoglobulin. A basophil contains histamine and is an integral part of hypersensitivity reactions.
The term that is used to refer to a primitive cell, capable of self-replication and differentiation, is which of the following? a) Reticulocyte b) Spherocyte c) Stem cell d) Band cell
c) Stem cell Explanation: The definition of a stem cell is a primitive cell, capable of self-replication and differentiation into myeloid or lymphoid stem cell. A band cell is a slightly immature neutrophil. A spherocyte is a red blood cell without central pallor. A reticulocyte is a slightly immature red blood cell.
A patient with a history of congestive heart failure has an order to receive one unit of packed red blood cells (RBCs). If the nurse hangs the blood at 12:00 pm, by what time must the infusion be completed? a) 6:00 pm b) 2:00 pm c) 3:00 pm d) 4:00 pm
d) 4:00 pm Explanation: When packed red blood cells (PRBCs) or whole blood is transfused, the blood should be administered within a 4-hour period because warm room temperatures promote bacterial growth.
The major function of neutrophils is which of the following? a) The rejection of foreign tissue b) The production of antibodies called immunoglobulin (Ig) c) Phagocytosis d) Destruction of tumor cells
c) Phagocytosis Explanation: Once the neutrophil is released into the circulation from the marrow, it stays there for only about 6 hours before it migrates into the body tissues to perform its function of phagocytosis (ingestion and digestion of bacteria and particles). Neutrophils die here within 1 to 2 days. T lymphocytes are responsible for rejection of foreign tissue and destruction of tumor cells. Plasma cells produce antibodies call immunoglobulin.
A patient who has idiopathic thrombocytopenia purpura (ITP) has a critically low platelet count. Which nursing intervention will be included in the care plan for a patient with ITP? a) Enforce strict contact isolation b) Administer eltrombopag (Promacta) c) Place patient in a private room d) Administer epoetin alfa (Epogen)
b) Administer eltrombopag (Promacta) Explanation: Thrombopoietin (TPO) is a cytokine that is necessary for the proliferation of megakaryocytes and subsequent platelet formation. Nonimmunogenic second-generation thrombopoietic growth factors (romiplastin [Nplate] and eltrombopag [Promacta]) were recently approved for the treatment of idiopathic thrombocytopenia purpura.
Which of the following nursing interventions should be incorporated into the plan of care for a patient with impaired liver function and low albumin levels? a) Apply prolonged pressure to needle sites or other sources of external bleeding b) Monitor temperature at least once per shift c) Monitor for edema at least once per shift d) Implement neutropenic precautions
c) Monitor for edema at least once per shift Explanation: Albumin is particularly important for the maintenance of fluid balance within the vascular system. Capillary walls are impermeable to albumin, so its presence in the plasma creates an osmotic force that keeps fluid within the vascular space. People with impaired hepatic function may have low concentrations of albumin, with a resultant decrease in osmotic pressure and the development of edema.
One hour after the completion of a fresh frozen plasma transfusion, a patient complains of shortness of breath and is very anxious. The patient's vital signs are BP 98/60, HR 110, temperature 99.4ºF, and SaO2 88%. Auscultation of the lungs reveals posterior coarse crackles to the mid and lower lobes bilaterally. Based on the symptoms, the nurse suspects the patient is experiencing which of the following problems? a) Delayed hemolytic reaction b) Bacterial contamination of blood c) Transfusion-related acute lung injury d) Exacerbation of congestive heart failure
c) Transfusion-related acute lung injury Explanation: Transfusion-related acute lung injury (TRALI) is a potentially fatal, idiosyncratic reaction that is defined as the development of acute lung injury occurring within 6 hours after a blood transfusion. It is more likely to occur when plasma and platelets are transfused. Onset is abrupt (usually within 6 hours of transfusion, often within 2 hours). Signs and symptoms include acute shortness of breath, hypoxia (arterial oxygen saturation [SaO2] less than 90%; pressure of arterial oxygen [PaO2] to fraction of inspired oxygen [FIO2] ratio of less than 300), hypotension, fever, and eventual pulmonary edema.
One hour after a transfusion of packed red cells is started; a patient develops redness on his trunk and complains of itching. The nurse stops the red blood cell (RBC) infusion and administers the ordered diphenhydramine (Benadryl) 25 mg po. Thirty minutes later, the redness and itching is gone. What is the next action the nurse should take? a) Send the blood back to the blood bank b) Position the patient in an upright position with the feet in a dependent position c) Obtain blood and urine samples from the patient d) Resume the transfusion
d) Resume the transfusion Explanation: Some patients develop urticaria (hives) or generalized itching during a transfusion. The cause of these reactions is thought to be a sensitivity reaction to a plasma protein within the blood component being transfused. Symptoms of an allergic reaction are urticaria, itching, and flushing. The reactions are usually mild and respond to antihistamines. If the symptoms resolve after administration of an antihistamine (e.g., diphenhydramine [Benadryl]), the transfusion may be resumed.
The physician orders a transfusion with packed red blood cells (RBCs) for a patient hospitalized with severe iron deficiency anemia. When blood is administered, what is the most important action the nurse can take to prevent a transfusion reaction? a) Verify the patient identification according to hospital policy b) Administer the blood as soon as it arrives c) Premedicate the patient with acetaminophen (Tylenol) d) Stay with the patient during the first 15 minutes of the transfusion
a) Verify the patient identification according to hospital policy Explanation: Acute hemolytic transfusion reactions are preventable. Improper identification is responsible for the majority of hemolytic transfusion reactions. Meticulous attention to detail in labeling blood samples and blood components and accurately identifying the recipient cannot be overemphasized. It is the nurse's responsibility to ensure that the correct blood component is transfused to the correct patient.
Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets? a) Myeloid stem cell b) Monocyte c) Neutrophil d) Lymphoid stem cell
a) Myeloid stem cell Explanation: The myeloid stem cell is responsible not only for all nonlymphoid white blood cells, but also for the production of red blood cells and platelets. Lymphoid cells produce either T or B lymphocytes. A monocyte is large WBC that becomes a macrophage when is leaves the circulation and moves into body tissues. A neutrophil is a fully mature WBC capable of phagocytosis.
A nursing instructor is reviewing the role and function of stem cells in the bone marrow with a group of nursing students. Following the explanation, the instructor asks the students to use their knowledge of anatomy and physiology to determine an alternate way in which adults with diseases that causes marrow destruction can resume production of blood cells. Which of the students' explanations is correct? a) The liver and spleen can resume production of blood cells through extramedullary hematopoiesis. b) The three cell types—erythrocytes, leukocytes, and platelets—can resume production of stem cells. c) Fat found in yellow bone marrow can be replaced by active marrow when more blood cell production is required. d) The remaining stem cells have the ability to continue with the process of self-replication creating an endless supply.
a) The liver and spleen can resume production of blood cells through extramedullary hematopoiesis. Explanation: In adults with disease that causes marrow destruction, fibrosis, or scarring, the liver and spleen can also resume production of blood cells by a process known as extramedullary hematopoiesis.
A nurse is teaching a patient with a vitamin B12 deficiency about appropriate food choices to increase the amount of B12 ingested with each meal. The nurse knows the teaching is effective based on which of the following patient statements? a) "I will eat more dairy products such as milk, yogurt, and ice cream every day." b) "I will eat a meat source such as chicken or pork with each meal." c) "I will eat a spinach salad with lunch and dinner." d) "I will increase my daily intake of orange vegetables such as sweet potatoes and carrots."
b) "I will eat a meat source such as chicken or pork with each meal." Explanation: Vitamin B12 is found only in foods of animal origin.
A patient with Hodgkin's disease had a bone marrow biopsy yesterday and is complaining of aching, rated at a 5 (on a 1-10 scale), at the biopsy site. After assessing the biopsy site, which of the following nursing interventions is most appropriate? a) Notify the physician b) Administer the ordered acetaminophen (Tylenol) 500 mg po c) Reposition the patient to a high Fowler's position and continue to monitor the pain d) Administer the ordered aspirin (ASA) 325 mg po
b) Administer the ordered acetaminophen (Tylenol) 500 mg po Explanation: After the marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing. Most patients have no discomfort after a bone marrow aspiration, but the site of a biopsy may ache for 1 or 2 days. Warm tub baths and a mild analgesic agent (e.g., acetaminophen [Tylenol]) may be useful. Aspirin-containing analgesic agents should be avoided it the immediate postprocedure period because they can aggravate or potentiate bleeding.
The physician performs a bone marrow biopsy from the posterior iliac crest on a patient with pancytopenia. What intervention should the nurse perform following the procedure? a) Pack the wound with half-inch sterile gauze b) Administer a topical analgesic to control pain at the site c) Apply pressure over the site for 5-7 minutes d) Elevate the head of the bed to 45 degrees
c) Apply pressure over the site for 5-7 minutes Explanation: Hazards of either bone marrow aspiration or biopsy include bleeding and infection. The risk of bleeding is somewhat increased if the patient's platelet count is low or if the patient has been taking a medication (e.g., aspirin) that alters platelet function. After the marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing.
The nurse recognizes the most common cause of iron deficiency anemia in an adult is which of the following? a) Chronic alcoholism b) Iron malabsorption c) Bleeding d) Lack of dietary iron
c) Bleeding Explanation: Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow). Lack of dietary iron is rarely the sole cause of iron deficiency anemia in adults. The source of iron deficiency should be investigated promptly, because iron deficiency in an adult may be a sign of bleeding in the GI tract or colon cancer.
A patient comes into the emergency room with complaints of an enlarged tongue. The tongue appears smooth and beefy red in color. The nurse also observes a 5-cm incision on the upper left quadrant of the abdomen. When questioned, the patient states, "I had a partial gastrostomy 2 years ago." Based on this information, the nurse attributes these symptoms to which of the following problems? a) Folic acid deficiency b) Vitamin A deficiency c) Vitamin B12 deficiency d) Vitamin C deficiency
c) Vitamin B12 deficiency Explanation: Because vitamin B12 is found only in foods of animal origin, strict vegetarians may ingest little vitamin B12. Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12-intrinsic factor complex is absorbed in the distal ileum. People who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and therefore the absorption of vitamin B12 may be diminished. The effects of either decreased absorption or decreased intake of vitamin B12 are not apparent for 2-4 years. This results in megaloblastic anemia. Some symptoms are smooth, beefy red, enlarged tongue and cranial nerve deficiencies.
A nurse is completing a detailed health history and assessment in the electronic medical record (EMR) on a patient with a disorder of the hematopoietic system. Based on the patient's responses, which of the following symptoms is the most common complaint associated with hematologic diseases? a) Blurred vision b) Dyspnea c) Severe headaches d) Extreme fatigue
d) Extreme fatigue Explanation: When assessing a patient with a disorder of the hematopoietic system, it is essential to assess for the most common symptom in hematologic diseases, which is extreme fatigue.
Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called which of the following? a) Blast cells b) Mast cells c) Monocytes d) Megaloblasts
d) Megaloblasts Explanation: Megaloblasts are abnormally large erythrocytes. Blast cells are primitive WBCs. Mast cells are cells found in connective tissue involved in defense of the body and coagulation. Monocytes are large WBCs that become macrophages when they leave the circulation and move into body tissues.
A nurse is reviewing a patient's morning lab results and notes a left shift in the band cells. Based on this observation, what interpretation can the nurse make from these results? a) The patient has leukopenia. b) The patient may be developing anemia. c) The patient has thrombocytopenia. d) The patient may be developing an infection.
d) The patient may be developing an infection. Explanation: The somewhat less mature granulocyte has a single-lobed, elongated nucleus and is called a band cell. Ordinarily, band cells account for only a small percentage of circulating granulocytes, although their percentage can increase greatly under conditions in which neutrophil production increases, such as infection. An increased number of band cells is sometimes called a left shift or shift to the left. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of white blood cells (WBCs) in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.
The nurse is completing a pretransfusion assessment to determine the history of previous transfusions as well as previous reactions to transfusions for a female patient. From the following list, what is the most important information to obtain from this patient prior to the transfusion? a) Number of pregnancies b) Family history of transfusion reactions c) Patient age d) Patient diagnosis
a) Number of pregnancies Explanation: The history should include the type of reaction, its manifestations, the interventions required, and whether any preventive interventions were used in subsequent transfusions. The nurse assesses the number of pregnancies a woman has had because a high number can increase her risk of reaction due to antibodies developed from exposure to fetal circulation. Other concurrent health problems should be noted, with careful attention paid to cardiac, pulmonary, and vascular disease.
Which of the following is a symptom of severe thrombocytopenia? a) Petechiae b) Dyspnea c) Inflammation of the tongue d) Inflammation of the mouth
a) Petechiae Explanation: Patients with severe thrombocytopenia have petechiae (i.e. pinpoint hemorrhagic lesions, usually more prominent on the trunk or anterior aspects of the lower extremities).
During a blood transfusion with packed red blood cells (RBCs), a patient begins to complain of chills, low back pain, and nausea. What priority action should the nurse take? a) Observe for additional symptoms and notify the physician b) Discontinue the infusion immediately and notify the physician c) Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing d) Slow the infusion rate and continue to monitor the patient every 15 minutes
c) Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing Explanation: The following steps are taken to determine the type and severity of the reaction: Stop the transfusion. Maintain the IV line with normal saline solution through new IV tubing, administered at a slow rate. Assess the patient carefully. Notify the physician. Continue to monitor the patient's vital signs and respiratory, cardiovascular, and renal status. Notify the blood bank that a suspected transfusion reaction has occurred and send the blood container and tubing to the blood bank for repeat typing and culture.
A patient with severe anemia is admitted to the hospital. Due to religious beliefs, the patient is refusing blood transfusions. The nurse anticipates drug therapy with which drug to stimulate the production of red blood cells? a) Eltrombopag (Promacta) b) Sargramostim (Leukine) c) Filgrastim (Neupogen) d) Epoetin alfa (Epogen)
d) Epoetin alfa (Epogen) Explanation: Erythropoietin (epoetin alfa [Epogen, Procrit]) is an effective alternative treatment for patients with chronic anemia secondary to diminished levels of erythropoietin. This medication stimulates erythropoiesis.