PrepU & Picmonic: CH 29 Nonmalignant Hematologic Disorders

A client with megaloblastic anemia reports mouth and tongue soreness. What instruction will the nurse give the client regarding eating while managing the client's symptoms? "Eat larger amounts of bland, soft foods less frequently." "Eat small amounts of bland, soft foods frequently." "Eat low-fiber blended foods only." "Eat cold, bland foods with a large amount of water."

"Eat small amounts of bland, soft foods frequently." Explanation: Because the client with megaloblastic anemia often reports mouth and tongue soreness, the nurse should instruct the client to eat small amounts of bland, soft foods frequently. The other answer choices do not factor in the client's mouth soreness or need for nutrition. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Megaloblastic Anemias, p. 918.

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy? "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal." "I will receive parenteral vitamin B12 therapy for the rest of my life." "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year." "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear."

"I will receive parenteral vitamin B12 therapy for the rest of my life." Explanation: Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Megaloblastic Anemias, p. 917.

A client with anemia is prescribed an oral iron supplement. Which statement indicates that teaching about this supplement has been effective? "I will stop taking it if my stool turns black." "I will take it in the morning with orange juice." "I will be sure to take this medication with food." "I will limit my intake of raw fruit and vegetables."

"I will take it in the morning with orange juice." Explanation: The client should be instructed to take the iron supplements on an empty stomach with a source of vitamin C such as orange juice. Iron supplements will turn the stool dark or black; this does not indicate that the supplement should be stopped. The supplement should be taken 1 hour before meals or 2 hours after a meal and not with a meal. The client should be instructed to increase the intake of high-fiber foods to reduce the risk of constipation. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Hypoproliferative Anemias, p. 915.

INDICATIONS Anemia

A deficiency in iron absorption leads to a decreased production of hemoglobin. Since hemoglobin is responsible for carrying oxygen throughout the body, the patient develops anemia and presents with fatigue and pallor. This drug also prevents iron deficiency associated with pregnancy or chronic blood loss. With iron deficiency anemia, the RBCs are microcytic and hypochromic.

Which nursing diagnosis should a nurse expect to see in a care plan for a client in sickle cell crisis? Imbalanced nutrition: Less than body requirements related to poor intake Impaired skin integrity related to pruritus Acute pain related to sickle cell crisis Disturbed sleep pattern related to external stimuli

Acute pain related to sickle cell crisis Explanation: In sickle cell crisis, sickle-shaped red blood cells clump together in a blood vessel, which causes occlusion, ischemia, and extreme pain. Therefore, Acute pain related to sickle cell crisis is the appropriate choice. Although nutrition is important, poor nutritional intake isn't necessarily related to sickle cell crisis. During sickle cell crisis, pain or another internal stimulus is more likely to disturb the client's sleep than external stimuli. Although clients with sickle cell anemia can develop chronic leg ulcers caused by small vessel blockage, they don't typically experience pruritus. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Sickle Cell Disease, p. 920.

SIDE EFFECTS Dark Stools

Although ferrous sulfate may cause dark green or black-colored stools, inform the patient that this is a harmless side effect and not indicative of bleeding.

CONSIDERATIONS Avoid Antacids

Antacids decrease the body's ability to absorb iron and should not be taken with ferrous sulfate.

Which nursing intervention should be incorporated into the plan of care to manage the delayed clotting process in a client with leukemia? Monitor temperature at least once per shift Apply prolonged pressure to needle sites or other sources of external bleeding Implement neutropenic precautions Eliminate direct contact with others who are infectious

Apply prolonged pressure to needle sites or other sources of external bleeding Explanation: For a client with leukemia, the nurse should apply prolonged pressure to needle sites or other sources of external bleeding. Reduced platelet production results in a delayed clotting process and increases the potential for hemorrhage. Implementing neutropenic precautions and eliminating direct contact with others are interventions to address the risk for infection. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, THROMBOTIC DISORDERS, p. 943.

SIDE EFFECTS Arthralgia

Arthralgia, or joint pain, may be a side effect of cobalamin therapy. Assess the patient's level of pain.

A nurse caring for a client who has hemophilia is getting ready to take the client's vital signs. What should the nurse do before taking a blood pressure? Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints. Ask if taking a blood pressure has ever produced pain in the upper arm. Ask if taking a blood pressure has ever caused bruising in the hand and wrist. Ask if taking a blood pressure has ever produced the need for medication.

Ask if taking a blood pressure has ever produced bleeding under the skin or in the arm joints. Explanation: Due to the client's enhanced risk for bleeding, before taking a blood pressure, the nurse asks the client if the use of a blood-pressure cuff has ever produced bleeding under the skin or in the arm joints. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Inherited Bleeding Disorders, p. 936.

A client in end-stage renal disease is prescribed epoetin alfa and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, what is the priority action taken by the nurse? Ensures the client has completed dialysis treatment Holds the epoetin alfa if the BUN is elevated Assesses the hemoglobin level Questions the administration of both medications

Assesses the hemoglobin level Explanation: Erythropoietin (epoetin alfa [Epogen]) with oral iron supplements can raise hematocrit levels in the client with end-stage renal disease. The nurse should check the hemoglobin prior to administration of erythropoietin, because too high a hemoglobin level can put the client at risk for heart failure, myocardial infarction, and cerebrovascular accident. Erythropoietin may be administered during dialysis treatments. The BUN will be elevated in the client with end-stage renal disease. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Hemolytic Anemias, p. 922.

A patient describes numbness in the arms and hands with a tingling sensation. The patient also frequently stumbles when walking. What vitamin deficiency does the nurse determine may cause some of these symptoms? Folate B12 Thiamine Iron

B12 Explanation: The hematologic effects of vitamin B12 deficiency are accompanied by effects on other organ systems, particularly the gastrointestinal tract and nervous system. Patients with pernicious anemia may become confused; more often, they have paresthesias in the extremities (particularly numbness and tingling in the feet and lower legs). They may have difficulty maintaining their balance because of damage to the spinal cord, and they also lose position sense (proprioception). Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Megaloblastic Anemias, p. 917.

The nurse is caring for a client with type 2 diabetes who take metformin to manage glucose levels. The nurse recognizes the client may be most at risk for which vitamin deficiency? Folate B12 A C

B12 Explanation: The medication metformin (Glucophage) increases the client's risk for developing B12 deficiency because the medication inhibits the absorption of B12. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Megaloblastic Anemias, p. 917.

Which of the following are assessment findings associated with thrombocytopenia? Select all that apply. Bradypnea Bleeding gums Hypertension Hematemesis Epistaxis

Bleeding gums Hematemesis Epistaxis Explanation: Pertinent findings of thrombocytopenia include: bleeding gums, epistaxis, hematemesis, hypotension, and tachypnea. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Thrombocytopenia, p. 932.

INTERVENTIONS Bone Marrow Transplant

Bone marrow transplant, also called Hematopoietic Stem Cell Transplantation (HSCT), is a popular therapy for sickle cell anemia. Hematopoietic cells give rise to all other types of blood cells in the body. HSCT involves transplanting hematopoietic cells into a patient with SCA, in an effort to restore production of non-sickled hemoglobin A.

Picmonic Cobalamin (Vitamin B12)

Cobalamin (Vitamin B12) is a purified form of vitamin B12 that promotes cell growth and reproduction, hematopoiesis, and myelin synthesis. It requires the intrinsic factor secreted by stomach parietal cells for effective absorption. This medication is indicated for vitamin B12 deficiency and pernicious anemia. Side effects may include hypokalemia, arthralgia, and dizziness. Cobalamin is administered orally or parenterally. Intravenous administration of cobalamin is ineffective due to rapid urinary excretion.

SIDE EFFECTS Dizziness

Cobalamin may lead to dizziness, weakness, or headache. Severe dizziness may be related to a serious allergic reaction and requires immediate medical attention.

A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor? Decreased total iron-binding capacity Increased reticulocyte count Decreased level of erythropoietin Increased mean corpuscular volume

Decreased level of erythropoietin Explanation: As renal function decreases, erythropoietin, which is produced by the kidney, also decreases. Because erythropoietin is produced outside the kidney, some erythropoiesis continues, even in patients whose kidneys have been removed. However, the number of red blood cells produced is small and the degree of erythropoiesis is inadequate. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, ANEMIA, p. 910.

The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions? Dilute the liquid preparation with another liquid such as juice and drink with a straw. Discontinue the use of iron if your stool turns black. Iron may cause indigestion and should be taken with an antacid such as Mylanta. Do not take medication with orange juice because it will delay absorption of the iron.

Dilute the liquid preparation with another liquid such as juice and drink with a straw. Explanation: Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid staining the teeth. Avoid taking iron simultaneously with an antacid, which interferes with iron absorption. Drink orange juice or take other forms of vitamin C with iron to promote its absorption. Expect iron to color stool dark green or black. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Hypoproliferative Anemias, p. 915.

The nurse is caring for a client with external bleeding. What is the nurse's priority intervention? Direct pressure Application of a tourniquet Pressure point control Elevation of the extremity

Direct pressure Explanation: Applying direct pressure to an injury is the initial step in controlling bleeding. Elevation reduces the force of flow, but direct pressure is the first step. The nurse may use pressure point control for severe or arterial bleeding. Pressure points (those areas where large blood vessels can be compressed against bone) include femoral, brachial, facial, carotid, and temporal artery sites. The nurse should avoid applying a tourniquet unless all other measures have failed, because it may further damage the injured extremity. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, ANEMIA, p. 910.

The nurse and the client are discussing some strategies for ingesting iron to combat the client's iron-deficiency anemia. Which is among the nurse's strategies? Taking iron pills with milk aids in absorption. Avoid vitamin C as it prevents absorption. Drink liquid iron preparations with a straw. Take iron with an antacid to avoid stomach upset.

Drink liquid iron preparations with a straw. Explanation: Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid staining the teeth. Avoid taking iron simultaneously with an antacid, which interferes with iron absorption. Drink orange juice or take other forms of vitamin C with iron to promote its absorption. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Hypoproliferative Anemias, p. 915.

The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia? Clustering of platelets with sickled red blood cells An increased number of erythrocytes Erythrocytes that are macrocytic and hyperchromic Erythrocytes that are microcytic and hypochromic

Erythrocytes that are microcytic and hypochromic Explanation: A blood smear reveals erythrocytes that are microcytic (smaller than normal) and hypochromic (lighter in color than normal). It does not reveal macrocytic (larger than normal) or hyperchromic erythrocytes. Clustering of platelets with sickled red blood cells would indicate sickle cell anemia. An increase in the number of erythrocytes would indicate polycythemia vera. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, ANEMIA, p. 910.

When assessing a client with a disorder of the hematopoietic or the lymphatic system, which assessment is most essential? Health history, such as bleeding, fatigue, or fainting Lifestyle assessments, such as exercise routines Age and gender Menstrual history

Health history, such as bleeding, fatigue, or fainting Explanation: When assessing a client with a disorder of the hematopoietic or the lymphatic system, it is essential to assess the client's health history. An assessment of drug history is essential because some antibiotics and cancer drugs contribute to hematopoietic dysfunction. Aspirin and anticoagulants may contribute to bleeding and interfere with clot formation. Because industrial materials, environmental toxins, and household products may affect blood-forming organs, the nurse needs to explore exposure to these agents. Menstrual history, age, gender, and lifestyle assessments, such as exercise routines and habits, do not directly affect the hematopoietic or lymphatic system. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Aplastic Anemia, p. 916.

CONSIDERATIONS May be Asymptomatic

If SCA is not diagnosed during infancy, patients with this disease may remain asymptomatic until they experience a crisis due to lack of adequate oxygenation, or dehydration.

CAUSE/MECHANISM Hemoglobin S (Genetic Defect)

In patients with SCA, a genetic defect causes normal hemoglobin A to be partially or completely replaced by hemoglobin S, depending on the severity of the disease.

CONSIDERATIONS Increased Risk of Infection

Individuals with SCA are at an increased risk for infection due to splenic damage. Autoinfarction of the spleen typically occurs after the age of ten and renders the spleen unable to destroy bacteria and other foreign substances in the body.

A client is receiving chemotherapy for cancer. The nurse reviews the client's laboratory report and notes that he has thrombocytopenia. To which nursing diagnosis should the nurse give the highest priority? Activity intolerance Impaired oral mucous membranes Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI Impaired tissue integrity

Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI Explanation: These are all appropriate nursing diagnoses for the client with thrombocytopenia. However, the risk of cerebral and GI hemorrhage and hypotension pose the greatest risk to the physiological integrity of the client. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Thrombocytopenia, p. 932.

The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned the co-worker may have? Iron deficiency anemia Megaloblastic anemia Aplastic anemia Sickle cell anemia

Iron deficiency anemia Explanation: People with iron deficiency anemia may crave ice, starch, or dirt; this craving is known as pica. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, ANEMIA, p. 912.

The nurse is performing an assessment for a client with anemia admitted to the hospital to have blood transfusions administered. Why would the nurse need to include a nutritional assessment for this patient? It is part of the required assessment information. It will determine what type of anemia the patient has. It is important for the nurse to determine what type of foods the patient will eat. It may indicate deficiencies in essential nutrients.

It may indicate deficiencies in essential nutrients. Explanation: A nutritional assessment is important, because it may indicate deficiencies in essential nutrients such as iron, vitamin B12, and folate. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, ANEMIA, p. 912.

ASSESSMENT Jaundice

Jaundice is common in patients with SCA due to the rapid breakdown (hemolysis) of abnormal red blood cells. Rapid hemolysis can lead to a build-up of bilirubin, causing noticeable discoloration of the skin and sclera.

CONSIDERATIONS Liquid can Stain Teeth

Liquid preparations of ferrous sulfate may stain teeth. Instruct the patient to dilute liquid iron preparations with juice or water, administer through a straw, and rinse the mouth after taking the medication.

A client with a diagnosis of pernicious anemia comes to the clinic reporting of numbness and tingling in his arms and legs. What do these symptoms indicate? Neurologic involvement Loss of vibratory and position senses Insufficient intake of dietary nutrients Severity of the disease

Neurologic involvement Explanation: In clients with pernicious anemia, numbness and tingling in the arms and legs and ataxia are the most common signs of neurologic involvement. Some affected clients lose vibratory and position senses. Jaundice, irritability, confusion, and depression are present when the disease is severe. Insufficient intake of dietary nutrients is not indicated by these symptoms Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Megaloblastic Anemias, p. 918.

ASSESSMENT Vaso Occlusive Crisis

Obstruction of blood vessels by sickled RBCs can block blood flow causing ischemia and pain. In patients who experience chronic vaso occlusive episodes, leg ulcers may develop. Symptoms of a vaso-occlusive crisis can include severe pain in the hands, feet, joints, and abdomen, stroke, changes in vision, yellowing of the skin and eyes, blood in the urine, and priapism (persistent painful erection).

INTERVENTIONS Oxygen

Oxygen can be used to treat hypoxia and prevent further sickling of RBCs. Oxygen therapy does not reverse the sickling that has already occurred, nor does it decrease pain due to sickling.

INTERVENTIONS Analgesics

Pain management is an essential element of treatment. Pain associated with a sickle cell crisis is severe and is often treated with opioid medications such as hydromorphone, or methadone, administered via a patient controlled analgesia (PCA) pump.

ASSESSMENT Vaso Occlusive Crisis Fever

Patients may present with a fever during a vaso-occlusive crisis.

INTERVENTIONS Increase Hydration

Patients should be educated on the importance of avoiding dehydration, as this can induce a sickle cell crisis. Maintaining adequate hydration is important to decrease the viscosity of blood and to ensure proper functioning of the kidneys. In a sickle cell crisis, fluids are administered intravenously.

ASSESSMENT Vaso Occlusive Crisis Sever Pain

Patients typically experience mild to excruciating pain during a vaso-occlusive crisis, due to tissue hypoxia. Pain commonly occurs in areas such as the abdomen, hands, and feet.

CONSIDERATIONS Avoid High Altitudes

Patients with SCA should avoid high altitudes, as the difference in availability of oxygen may cause the patient to experience a sickling crisis.

A nurse is caring for a client with severe anemia. The client is tachycardic and reports dizziness and exertional dyspnea. What signs and symptoms might develop if this client goes into heart failure? Fever Peripheral edema Nausea and vomiting Migraine

Peripheral edema

INDICATIONS Pernicious Anemia

Pernicious anemia is a potentially fatal condition caused by a lack of intrinsic factor necessary for vitamin B12 absorption. Administering cyanocobalamin (cobalamin) in patients lacking the intrinsic factor helps normalize the production of red blood cells and quickly reverses the effects of anemia.

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters? Fibrinogen level, WBC, and platelet count Platelet count, prothrombin time, and partial thromboplastin time Thrombin time, calcium levels, and potassium levels Platelet count, blood glucose levels, and white blood cell (WBC) count

Platelet count, prothrombin time, and partial thromboplastin time Explanation: The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels aren't used to confirm a diagnosis of DIC. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, DISSEMINATED INTRAVASCULAR COAGULATION, p. 940.

A client awaiting a bone marrow aspiration asks the nurse to explain where on the body the procedure will take place. What body part does the nurse identify for the client? Ankle Femur Sternum Posterior iliac crest

Posterior iliac crest Explanation: In adults, bone marrow is usually aspirated from the posterior iliac crest and rarely from the sternum. Bone marrow is not aspirated from the femur or ankle. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders.

CONSIDERATIONS Prophylactic Antibiotics

Prophylactic administration of penicillin is recommended, starting at two months of age to reduce a child's risk of infection. Prophylactic antibiotics can be discontinued when the child reaches five years of age.

The nurse is screening donors for blood donation. Which client is an acceptable donor for blood? Has a history of viral hepatitis as a teenager 10 years ago Received a blood transfusion within 1 year Had a dental extraction 2 days ago for caries in a tooth Reports having a cold 1 month ago that resolved quickly

Reports having a cold 1 month ago that resolved quickly Explanation: Donors must meet certain requirements to be able to donate blood. A client should be in good health, such as the client who had a cold more than 1 month ago that resolved quickly. Those excluded from donating blood have a history of viral hepatitis, report a blood transfusion within 12 months, and had a dental extraction within 72 hours. The reason for exclusion is that they are at increased risk of transmitting an infectious disease. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders.

Picmonic Sickle Cell Anemia Interventions

Sickle cell anemia (SCA) is an autosomal recessive genetic disorder that causes normal hemoglobin A to be partially or completely replaced by hemoglobin S. Interventions to treat sickle cell anemia, or to lessen symptoms associated with the disease include: maintaining adequate hydration and oxygenation, analgesics and warm compresses for pain, hydroxyurea, and hematopoietic stem cell transplantation. Patients with this disease should avoid high altitudes, dehydration, and strenuous exercise, as these may induce sickling of RBCs, causing a crisis. Prophylactic antibiotics and pneumococcal and meningococcal vaccines are also strongly encouraged in these patients to reduce the risk of infection.

CONSIDERATIONS Prominent in African Americans

Sickle cell anemia is common among African Americans. Although it can occur in other ethnicities, the incidence among these populations is lower.

After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm3. What term should the nurse use to describe this low platelet count? Leukopenia Thrombocytopenia Neutropenia Anemia

Thrombocytopenia Explanation: A normal platelet count is 140,000 to 400,000/mm3 in adults. Chemotherapeutic agents produce bone marrow depression, resulting in reduced red blood cell counts (anemia), reduced white blood cell counts (leukopenia), and reduced platelet counts (thrombocytopenia). Neutropenia is the presence of an abnormally reduced number of neutrophils in the blood and is caused by bone marrow depression induced by chemotherapeutic agents. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Thrombocytopenia, p. 932.

CAUSE/MECHANISM Sickle Shaped RBCs

Unlike normal RBCs that are shaped like biconcave discs, RBCs are sickle or crescent-shaped in patients with SCA. Due to their abnormal shape, sickle-shaped RBCs tend to stick together, blocking blood flow within blood vessels throughout the body.

A nurse on a hematology/oncology floor is caring for a client with aplastic anemia. Which would not be included in the client's discharge instructions? Encourage frequent handwashing. Plan for frequent periods of rest. Use a disposable razor when shaving. Avoid contact with family/friends who are sick.

Use a disposable razor when shaving. Explanation: People with aplastic anemia usually have insufficient erythrocytes, leukocytes, and platelets. Encourage behaviors that will lower the risk for bleeding. Avoiding contact with people who are sick reduces the risk of acquiring an infection. Handwashing reduces the risk of acquiring an infection. Anemia can cause fatigue and shortness of breath with even mild exertion. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Aplastic Anemia, p. 916.

CONSIDERATIONS Vaccines

Vaccines, such as the pneumococcal and meningococcal vaccines, are recommended for children to reduce the risk of infection. Additionally, Haemophilus influenzae, influenza, and hepatitis immunizations should be administered. Remember, individuals with SCA are at an increased risk for infection due to splenic damage.

INDICATIONS Vitamin Deficiency

Vitamin B12 deficiency is commonly caused by impaired absorption related to celiac disease or low gastric acidity. Vitamin B12 deficiency causes neuronal demyelination and may lead to irreversible neurological damage. A lack of this vitamin prevents folic acid activation and leads to underproduction of white blood cells and platelets. Since humans cannot biosynthesize this vitamin, patients deficient in vitamin B12 must consume animal products, vitamin B12-fortified food, or a supplement.

Which medication is the antidote to warfarin? Protamine sulfate Aspirin Vitamin K Clopidogrel

Vitamin K Explanation: The antidote for warfarin is vitamin K. Protamine sulfate is the antidote for heparin. Aspirin and clopidogrel are both antiplatelet medications. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Protein C Deficiency, p. 945.

INTERVENTIONS Warm Compress

Warm compresses encourage blood vessels to dilate, and can be used to alleviate pain. Cold compresses or ice packs should never be used, as they can decrease circulation increasing the risk of a sickle cell crisis.

A nurse cares for clients with hematological disorders and notes that women are diagnosed with hemochromatosis at a much lower rate than men. What is the primary reason for this? Women have lower hemoglobin levels Women rarely manifest the gene expression Women require grater folic acid supplementation Women lose iron through menstrual cycles

Women lose iron through menstrual cycles Explanation: Hemochromatosis is a genetic condition where excess iron is absorbed in the GI tract and deposited in various organs, making them dysfunctional. Women are often less affected than men because women lose excess iron through their menstrual cycles. The other answer choices are not correct reasons why women are impacted less than men with hemochromatosis. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Hypoproliferative Anemias, p. 914.

A home care nurse visits a client diagnosed with atrial fibrillation who is ordered warfarin. The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching? "I'll eat four servings of fresh, dark green vegetables every day." "I'll report unexplained or severe bruising to my doctor right away." "I'll use an electric razor to shave." "I'll watch my gums for bleeding when I brush my teeth."

"I'll eat four servings of fresh, dark green vegetables every day." Explanation: The client requires additional teaching if he states that he'll eat four servings of dark green vegetables every day. Dark, green vegetables contain vitamin K, which reverses the effects of warfarin. The client should limit his intake to one to two servings per day. The client should report bleeding gums and severe or unexplained bruising, which may indicate an excessive dose of warfarin. The client should use an electric razor to prevent cutting himself while shaving. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, THROMBOTIC DISORDERS, p. 945.

A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving: A-positive blood to an A-negative client. O-positive blood to an A-positive client. B-positive blood to an AB-positive client. O-negative blood to an O-positive client.

A-positive blood to an A-negative client. Explanation: An acute hemolytic reaction occurs when there is an ABO or Rh incompatibility. For example, giving A blood to a B client would cause a hemolytic reaction. Likewise, giving Rh-positive blood to an Rh-negative client would cause a hemolytic reaction. It's safe to give Rh-negative blood to an Rh-positive client if there is a blood type compatibility. O-negative blood is the universal donor and can be given to all other blood types. AB clients can receive either A or B blood as long as there isn't an Rh incompatibility. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders.

SIDE EFFECTS Nausea & Vomiting

Administering ferrous sulfate increases the body's amount of iron and subsequently affects the GI system's ability to absorb the mineral. Symptoms of GI distress caused by iron preparations include nausea and vomiting. Inform the patient that continued therapy often leads to decreased symptoms.

INTERVENTIONS Hydroxyurea

Among individuals with SCA, those who have higher levels of Hgb F (fetal hemoglobin) typically have fewer complications of the disease. Hydroxyurea is a chemotherapy drug that has been clinically effective in increasing production of hemoglobin F, decreasing the reactive neutrophil count, increasing RBC volume and hydration, and altering the adhesion of sickle RBCs to the endothelium, thereby reducing complications.

SIDE EFFECTS Hypokalemia

Cobalamin increases the production of erythrocytes, which require potassium for synthesis. As more potassium is used for erythrocyte production, the level of serum potassium decreases and results in hypokalemia. Assess the patient for weakness, cramping, and abnormal arrhythmias.

CONSIDERATIONS IM Injection for Pernicious Anemia

Cobalamin may be administered via IM injection for patients with pernicious anemia related to a lack of intrinsic factor or parietal cell atrophy. Patients with B12 malabsorption may require lifelong cobalamin therapy. Although injecting this drug is generally well tolerated, the patient may experience some pain or redness at the injection site. It can also be given as a deep subcutaneous injection.

A patient with end-stage kidney disease (ESKD) has developed anemia. What laboratory finding does the nurse understand to be significant in this stage of anemia? Creatinine level of 6 mg/100 mL Calcium level of 9.4 mg/dL Magnesium level of 2.5 mg/dL Potassium level of 5.2 mEq/L

Creatinine level of 6 mg/100 mL Explanation: The degree of anemia in patients with end-stage renal disease varies greatly; however, in general, patients do not become significantly anemic until the serum creatinine level exceeds 3 mg/100 mL. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders.

ASSESSMENT Vaso Occlusive Crisis Priapism

Sickled RBCs may prevent blood from leaving the penis during a vaso-occlusive crisis, causing priapism or a prolonged, painful erection.

CONSIDERATIONS Avoid Strenuous Exercise

Strenuous exercise should also be avoided. Dehydration or lack of adequate oxygenation associated with this type of exercise could induce a sickling crisis.

SIDE EFFECTS GI Distress

The body's level of iron is regulated by intestinal absorption. Ferrous sulfate may cause GI distress such as heartburn (pyrosis), constipation, diarrhea, and bloating. These symptoms are dose-dependent and typically decrease with continued drug therapy. Patients experiencing constipation may benefit from a stool softener or laxative.

CONSIDERATIONS Never Give IV

Cobalamin may be administered orally, parenterally (IM or deep SQ injection), or intranasally. Since cobalamin is a water-soluble vitamin, do not administer intravenously due to rapid urine excretion resulting in minimal therapeutic effect.

CONSIDERATIONS Keep out of Reach from Children

Since excessive amounts of iron is toxic, accidental or intentional overdose leads to poisoning. Iron preparations should be stored in childproof containers and kept out of reach of children.

CONSIDERATIONS Caution with GI Disorders

Since iron preparations cause GI effects, this medication may worsen symptoms associated with peptic ulcers, ulcerative colitis, and regional enteritis. Patients with these conditions should use this medication cautiously and avoid oral iron preparations.

When teaching a client with iron deficiency anemia about appropriate food choices, the nurse encourages the client to increase the dietary intake of which foods? Dairy products Fruits high in vitamin C, such as oranges and grapefruits Berries and orange vegetables Beans, dried fruits, and leafy, green vegetables

Beans, dried fruits, and leafy, green vegetables Explanation: Food sources high in iron include organ meats (e.g., beef or calf liver, chicken liver), other meats, beans (e.g., black, pinto, and garbanzo), leafy and green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Iron Deficiency Anemia, pp. 914-915.

MECHANISM Ferrous Salts

Iron is an essential component of hemoglobin, myoglobin, and certain enzymes. The bone marrow utilizes iron to make hemoglobin, the liver stores iron as ferritin, and the muscles incorporate iron to produce myoglobin. The body requires iron to transport oxygen throughout the body.

MECHANISM Vitamin B12

Vitamin B12 helps activate folic acid, an essential component for DNA synthesis and cell growth and division. This vitamin is activated by intrinsic factor secreted by stomach parietal cells. Vitamin B12 is essential for proper cell growth and division, especially in the bone marrow, GI tract, and nervous system.

Which nursing instructions help parents of a child with hemophilia provide a safe home environment for their child? "Talk with your child about home safety and have him problem-solve hypothetical situations about his health." "Pad the corners of coffee tables when your child is a toddler and provide kneepads for sports when the child is older." "Establish a written emergency plan including what to do in specific situations and the names and phone numbers of emergency contacts." "Be a role model to your child by wearing a helmet when riding a bike so your child will, too."

"Establish a written emergency plan including what to do in specific situations and the names and phone numbers of emergency contacts." Explanation: Establishing a written emergency plan that includes what to do in specific situations helps the family provide safety measures for their child with hemophilia. Padding corners of furniture and using kneepads don't help provide a safe home environment for children of all ages. Telling the parents to be a role model by wearing a bike helmet is only applicable to children who are old enough to emulate their parent's behaviors. Having the child problem-solve hypothetical health situations doesn't help provide a safe environment; it addresses problem solving. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Inherited Bleeding Disorders, p. 936.

A client is hospitalized 3 days prior to a total hip arthroplasty and reports a high level of pain with ambulation. The client has been taking warfarin at home, which is now discontinued. To prevent the formation of blood clots, which action should the nurse take? Have the client limit physical activity. Administer the prescribed enoxaparin (Lovenox). Monitor partial thromboplastin (PTT) time. Encourage a diet high in vitamin K.

Administer the prescribed enoxaparin (Lovenox). Explanation: Clients who are prescribed warfarin at home and need to have a major invasive procedure stop taking warfarin prior to the procedure. Low molecular weight heparin, such as enoxaparin, may be used until the procedure is performed. The client will continue with a diet that has a daily consistent amount of vitamin K. The client needs to ambulate frequently throughout the day. Prothrombin (PT) time is monitored, not PTT, when warfarin had been administered. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders.

A client is being treated for DIC and the nurse has prioritized the nursing diagnosis of Risk for Deficient Fluid Volume Related to Bleeding. How can the nurse best determine if goals of care relating to this diagnosis are being met? Assess the client's level of consciousness frequently. Closely monitor intake and output. Assess for edema. Assess skin integrity frequently.

Closely monitor intake and output. Explanation: The client with DIC is at a high risk of deficient fluid volume. The nurse can best gauge the effectiveness of care by closely monitoring the client's intake and output. Each of the other assessments is a necessary element of care, but none addresses fluid balance as directly as close monitoring of intake and output. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, DISSEMINATED INTRAVASCULAR COAGULATION, p. 940.

CONSIDERATIONS Take Between Meals

Iron is best absorbed on an empty stomach. Certain dietary components may chelate iron and prevent it from being absorbed. Patients should thus be instructed not to take this medication with food. However, this will increase the incidence of GI upset. If patients cannot tolerate the increased GI side effects, they can be instructed to take iron with meals to increase medication adherence

A client diagnosed with systemic lupus erythematosus comes to the emergency department with severe back pain. The client is taking prednisone daily and reported feeling pain after manually opening the garage door. What adverse effect of long-term corticosteroid therapy is most likely responsible for the pain? Truncal obesity Hypertension Muscle wasting Osteoporosis

Osteoporosis Explanation: Hypertension, osteoporosis, muscle wasting, and truncal obesity are all adverse effects of long-term corticosteroid therapy; however, osteoporosis commonly causes compression fractures of the spine. Hypertension, muscle wasting, and truncal obesity aren't likely to cause severe back pain. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Immune Thrombocytopenic Purpura, p. 934.

Picmonic Sickle Cell Anemia Assessment

Sickle cell anemia (SCA) is an autosomal recessive genetic disorder that causes normal hemoglobin A to be partially or completely replaced by hemoglobin S. This disease is prominent among African Americans, although it can occur across all ethnicities. Unlike normal RBCs that are shaped like biconcave discs, RBCs are sickled or crescent-shaped in patients with SCA. In these patients, RBCs undergo rapid breakdown (hemolysis), which can lead to a build-up of bilirubin, causing noticeable yellowing of the skin and sclera. Patients may also experience severe pain in the hands, feet, joints, and abdomen. Other clinical manifestations include changes in vision, blood in the urine, and persistent, painful penile erections. Symptoms of thrombosis and infarction (pulmonary embolism and stroke) can occur during a vaso-occlusive crisis, in which blood vessels are obstructed by sickled RBCs causing tissue ischemia and pain. Keep in mind, that individuals with SCA are at an increased risk for infection due to splenic damage. If SCA is not diagnosed during infancy, patients with this disease may remain asymptomatic until a sickle cell crisis occurs.

A patient is taking prednisone 60 mg per day for the treatment of an acute exacerbation of Crohn's disease. The patient has developed lymphopenia with a lymphocyte count of less than 1,500 mm3. What should the nurse monitor the client for? Abdominal pain The onset of a bacterial infection Diarrhea Bleeding

The onset of a bacterial infection Explanation: Lymphopenia (a lymphocyte count less than 1,500/mm3) can result from ionizing radiation, long-term use of corticosteroids, uremia, infections (particularly viral infections), some neoplasms (e.g., breast and lung cancers, advanced Hodgkin disease), and some protein-losing enteropathies (in which the lymphocytes within the intestines are lost) (Kipps, 2010). When lymphopenia is mild, it is often without sequelae; when severe, it can result in bacterial infections (due to low B lymphocytes) or in opportunistic infections (due to low T lymphocytes). Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, NEUTROPENIA, p. 929.

A client is treated for anemia. What is the nurse's best understanding about the correlation between anemia and the client's iron stores? There is an inverse relationship between iron stores and hemoglobin levels. There is a weak correlation between iron stores and hemoglobin levels. There is a strong correlation between iron stores and hemoglobin characteristics. There is a strong correlation between iron stores and hemoglobin levels.

There is a strong correlation between iron stores and hemoglobin levels. Explanation: A strong correlation exists between laboratory values that measure iron stores and hemoglobin levels. After iron stores are depleted (as reflected by low serum ferritin levels), the hemoglobin level falls. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Hypoproliferative Anemias, p. 914.

A pregnant woman is hospitalized as the result of sickle-cell crisis. Which finding indicates the outcome has been achieved for this client? Exhibits a temperature more than 100.3°F Describes the importance of staying cool Takes hydroxyurea during her pregnancy Reports joint pain less than 3 on a scale of 0 to 10

Reports joint pain less than 3 on a scale of 0 to 10 Explanation: An expected outcome for a client experiencing a sickle-cell crisis is control and reduction of pain. Hydroxyurea is contraindicated in pregnancy because of the risk it poses for congenital abnormalities. An indication that the client is free from infection is exhibiting a normal temperature; 100.3°F is an elevated temperature. To minimize crises, the client needs to stay warm not cool. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Sickle Cell Disease, p. 920.

Parents arrive to the clinic with their young child and inform the nurse the child has just been diagnosed with sickle cell disease. The parents ask the nurse how this could have happened and which one of them is the carrier. What is the best response by the nurse? "It is an acquired, not a hereditary disorder." "Most likely, the father is the carrier of the gene." "The trait is passed down through the mother." "The child must inherit two defective genes, one from each parent."

"The child must inherit two defective genes, one from each parent." Explanation: Sickle cell disease is a hereditary disorder. To manifest this disorder, a person must inherit two defective genes, one from each parent, in which case all the hemoglobin is inherently abnormal. If the person inherits only one gene, the person carries the sickle cell trait. The hemoglobin of those who have sickle cell trait is about 40% affected. The other distractors are incorrect due to these factors. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Sickle Cell Disease, p. 919.

A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply. Inadequate formed white blood cells Infection Destruction of normally formed red blood cells Blood loss Abnormal erythrocyte production

Destruction of normally formed red blood cells Blood loss Abnormal erythrocyte production Explanation: Most anemias result from (1) blood loss, (2) inadequate or abnormal erythrocyte production, or (3) destruction of normally formed red blood cells. The most common types include hypovolemic anemia, iron-deficiency anemia, pernicious anemia, folic acid deficiency anemia, sickle cell anemia, and hemolytic anemias. Although each form of anemia has unique manifestations, all share a common core of symptoms. Anemia does not result from infection or inadequate formed white blood cells. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, ANEMIA, p. 913.

A nurse provides nutritional information for a patient diagnosed with an iron-deficiency anemia. What education should the nurse provide? Take an iron supplement with meals to reduce gastric irritation. Decrease the intake of high-fat red meats, especially organ meats. Increase the intake of green, leafy vegetables. Decrease the intake of citrus fruits because they interfere with iron absorption.

Increase the intake of green, leafy vegetables. Explanation: Leafy greens, such as spinach, kale, swiss chard, collard and beet greens contain between 2.5-6.4 mg of iron per cooked cup. Clients should be encouraged to consume more green, leafy vegetables. Red meats, especially organ meats, are iron-rich foods and the client should not be discouraged from eating them. Vitamin C sources (citrus fruit and juices) enhance the absorption of iron, which should be taken 1 hour before or 2 hours after a meal. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Hypoproliferative Anemias, p. 915.

A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is most appropriate for this client? Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients Fatigue related to decreased hemoglobin and hematocrit Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit Risk for falls related to complaints of dizziness

Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit Explanation: The symptoms indicate impaired tissue perfusion due to a decrease in the oxygen-carrying capacity of the blood. Cardiac status should be carefully assessed. When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly) and by peripheral edema. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Sickle Cell Disease, pp. 919-923.

Picmonic Iron (Ferrous Sulfate)

Iron (Ferrous Sulfate) is an inexpensive drug of choice for treating and preventing iron deficiency anemia. The administration of iron promotes hemoglobin production necessary for carrying oxygen throughout the body. Ferrous sulfate is indicated for treating iron deficiency anemia. Side effects include constipation, diarrhea, nausea, vomiting, and dark green or black colored stools. Instruct the patient to take this medication between meals and to avoid concurrent antacid use. Teach the patient about measures to prevent liquid preparations from staining teeth and to keep this medication out of reach of children. This medication may worsen GI symptoms and should be used with caution in patients with peptic ulcers, ulcerative colitis, and regional enteritis.

A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? Sore tongue, dyspnea, and weight gain Pallor, tachycardia, and a sore tongue Angina pectoris, double vision, and anorexia Pallor, bradycardia, and reduced pulse pressure

Pallor, tachycardia, and a sore tongue Explanation: Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina pectoris; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, Megaloblastic Anemias, p. 917.

A nurse is caring for a client with severe anemia. The client is tachycardic and reports dizziness and exertional dyspnea. What signs and symptoms might develop if this client goes into heart failure? Fever Peripheral edema Nausea and vomiting Migraine

Peripheral edema Explanation: Cardiac status should be carefully assessed in clients with anemia. When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms such as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly), and by peripheral edema. Nausea, migraine, and fever are not associated with heart failure. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders, ANEMIA, p. 912.

The nurse obtains a unit of blood for the client, Donald D. Smith. The name on the label on the unit of blood reads Donald A. Smith. All the other identifiers are correct. What action should the nurse take? Administer the unit of blood Check with the blood bank first and then administer the blood with their permission Refuse to administer the blood Ask the client if he was ever known as Donald A. Smith

Refuse to administer the blood Explanation: To ensure a safe transfusion, all components of the identification must be correct. The nurse should refuse to administer the blood and notify the blood bank about the discrepancy. The blood bank should then take the necessary steps to correct the name on the label on the unit of blood. Chapter 29: Management of Patients with Nonmalignant Hematologic Disorders.