PREPU: CH 32 Ass of Hematologic Function and Treatment Modalities

The nurse is completing a physical assessment on a client's lymphatic system. The nurse should palpate for enlarged nodes in which areas? Select all that apply.

Correct response: Popliteal Inguinal Submental Neck Explanation: Palpable lymph node areas include: popliteal, inguinal, submental, and neck. The spinal region does not contain palpable lymph nodes.

Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following?

Liver Explanation: Albumin is produced by the liver. Albumin is not produced in the pancreas, kidney, or large intestine.

The physician believes that the patient has a deficiency in the leukocyte responsible for cell-mediated immunity. What should the nurse check the WBC count for?

T lymphocytes Explanation: T lymphocytes are responsible for cell-mediated immunity, in which they recognize material as "foreign," acting as a surveillance system.

Which term refers to a form of white blood cell involved in immune response?

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.

A client tells the nurse that he would like to donate blood before his abdominal surgery next week. What should be the nurse's first action?

Explain the time frame needed for autologous donation. Explanation: Preoperative autologous donations are ideally collected 4 to 6 weeks before surgery. The nurse should first explain that time frame to this client. Surgery is scheduled in one week which means that autologous blood donation may not be an option for this client. A list of donation centers can be provided to the client; and even though iron is recommended and 2 units of blood may be suggested, the first action is to tell the client about the needed time frame for donation.

A patient with chronic kidney disease is being examined by the nurse practitioner for anemia. The nurse has reviewed the laboratory data for hemoglobin and RBC count. What other test results would the nurse anticipate observing?

Decreased level of erythropoietin Explanation: Differentiation of the primitive myeloid stem cell into an erythroblast is stimulated by erythropoietin, a hormone produced primarily by the kidney. If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (i.e., anemia), or with people living at high altitudes with lower atmospheric oxygen concentrations, erythropoietin levels increase. The increased erythropoietin then stimulates the marrow to increase production of erythrocytes. The entire process of erythropoiesis typically takes 5 days (Cook, Ineck, & Lyons, 2011). For normal erythrocyte production, the bone marrow also requires iron, vitamin B12, folate, pyridoxine (vitamin B6), protein, and other factors. A deficiency of these factors during erythropoiesis can result in decreased red cell production and anemia.

A client in end-stage renal disease is prescribed epoetin alfa (Epogen) and oral iron supplements. Before administering the next dose of epoetin alfa and oral iron supplement, the nurse

Assesses the hemoglobin level Explanation: Erythropoietin 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.

A patient will need a blood transfusion for the replacement of blood loss from the gastrointestinal tract. The patient states, "That stuff isn't safe!" What is the best response from the nurse?

"I understand your concern. The blood is carefully screened but is not completely risk free." Explanation: Despite advances in donor screening and blood testing, certain diseases can still be transmitted by transfusion of blood components (Chart 32-4).

A nurse is teaching a client 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 statement by the client?

"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.

Which client is not a candidate for blood donation according to the American Heart Association?

26 year old female with hemoglobin 11.0 g/dL Explanation: Clients must meet the following criteria to be eligible as blood donors: body weight at least 50 kg; pulse rate regular between 50 and 100 bpm; systolic BP 90 to 180 mmHg and diastolic 50 to 100 mmHg; hemoglobin level at least 12.5 g/dL for women. There is no upper age limit to donation.

A client with a history of congestive heart failure has an order to receive 1 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?

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.

In normal blood, monocytes account for approximately what percentage of the total leukocyte count?

5% Explanation: Monocytes account for approximately 5% of the total leukocyte count. The other percentages are incorrect.

G-CSF (filgrastim [Neupogen]) is prescribed for a client with bone marrow suppression. What medication administration teaching should the nurse provide to the client?

Assist the client in identifying appropriate subcutaneous injection sites. Explanation: Neupogen is administered subcutaneously on a daily basis.

A client with a history of sickle cell anemia has developed iron overload from repeated blood transfusions. What treatment does the nurse anticipate will be prescribed?

Chelation therapy Explanation: Chelation therapy is prescribed to treat iron overload. Hepatitis B immunization helps immunize against hepatitis B. Red blood cell phenotyping helps decreased sensitization. A white blood cell filter protects against cytomegalovirus and some sensitization and febrile reactions.

The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise?

Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Explanation: Isometric exercise induce contraction of skeletal muscle so that it compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Isometric exercises do not have an aerobic effect and should not increase the heart rate; although, it may increase blood pressure. Isometric exercise does not decrease the workload of the heart. Arterial flow moves blood flow away from the heart after being oxygenated.

The nurse should be alert to which adverse assessment finding when transfusing a unit of packed red blood cells (PRBCs) too rapidly?

Crackles auscultated bilaterally Explanation: Increasing the flow rate of a blood transfusion too rapidly can result in circulatory overload. Fluid overload can be manifested by crackles in the lungs. A decreased respiratory rate and decreased temperature are not manifestations of fluid overload. Pain and tenderness in the calf area may indicate a thrombosis which is not as common a manifestation as fluid overload.

The nurse is caring for a client who had undergone hemodilution during surgery. Immediately after surgery, the nurse expects to see which lab result?

Decreased hematocrit Explanation: The added intravenous solutions used in hemodilution dilute the concentration of erythrocytes and lower the hematocrit. Adverse outcomes include tissue ischemia, particularly in the kidneys. These adverse outcomes can be manifested as low arterial oxygen saturation and elevated creatinine levels.

A client receiving a unit of packed red blood cells (PRBCs) has been prescribed morphine 1 mg intravenously now for pain. What is the best method for the nurse to administer the morphine?

Disconnect the blood tubing, flush with normal saline, and administer morphine. Explanation: Never add medications to blood or blood products. The transfusion must be temporarily stopped in order to administer the morphine.

The charge nurse should intervene when observing a new nurse perform which action after a client has suffered a possible hemolytic blood transfusion reaction?

Disposing of the blood container and tubing in biohazard waste. Explanation: The blood container and tubing should be returned to the blood bank for repeat typing and culture, and the blood bank should be notified of the reaction. A urine sample is collected as soon as possible to detect hemoglobin in the urine. Documenting the client's reaction in the medical record is an appropriate action.

A client receiving a blood transfusion complains of shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the healthcare provider?

Ensure there is an oxygen delivery device at the bedside. Explanation: The client is exhibiting signs of circulatory overload. After stopping the transfusion and notifying the healthcare provider, the nurse should place the client in a more upright position with the legs dependent to decrease workload on the heart. The IV line is kept patent in case emergency medications are needed. Oxygen and morphine may be needed to treat severe dyspnea. Administering an anti-anxiety agent is not a priority action over ensuring oxygen is available.

A client complains of extreme fatigue. Which system should the nurse suspect is most likely affected?

Hematological Explanation: The most common symptom in hematologic diseases is extreme fatigue.

The client's CBC with differential reveals small-shaped hemoglobin molecules. The nurse expects to administer which medication to this client?

Iron Explanation: With iron deficiency, the erythrocytes produced by the marrow are small and low in hemoglobin. Vitamin B12 and folate deficiencies are characterized by the production of abnormally large erythrocytes. Fresh frozen plasma are infused due to a low platelet level, not light-colored hemoglobin.

A patient who has long-term packed RBC (PRBC) transfusions has developed symptoms of iron toxicity that affect liver function. What immediate treatment should the nurse anticipate preparing the patient for that can help prevent organ damage?

Iron chelation therapy Explanation: Iron overload is a complication unique to people who have had long-term PRBC transfusions. One unit of PRBCs contains 250 mg of iron. Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. Over time, the excess iron deposits in body tissues and can cause organ damage, particularly in the liver, heart, testes, and pancreas. Promptly initiating a program of iron chelation therapy can prevent end-organ damage from iron toxicity.

The nurse should notify the healthcare provider before administering fresh frozen plasma (FFP) based on which assessment finding?

Jugular venous distention Explanation: During the pre-transfusion assessment, the nurse should carefully inspect for any signs of cardiac failure, such as jugular venous distention. The sclera should be examined for icterus; white is an expected finding. Weak pedal pulses would be a sign of cardiac failure. Tenting skin turgor is a sign of dehydration; low vascular volume would be a cause for transfusion, not a contraindication.

A client in acute renal failure has been prescribed 2 units of packed red blood cells (PRBCs). The nurse explains to the client that the blood transfusion is most likely needed for which of the following reasons?

Lack of erythropoietin Explanation: The kidneys produce erythropoietin, a hormone that stimulates red blood cell production. A lack of this hormone is the most likely reason for blood transfusion due to the acute kidney failure. There is no indication for a nephrectomy in this question. A blood transfusion will not necessarily increase the effectiveness of dialysis. Transfusing a client with hypervolemia could lead to circulatory overload.

The nurse is preparing a patient for a bone marrow aspiration and biopsy from the site of the posterior superior iliac crest. What position will the nurse place the patient in?

Lateral position with one leg flexed Explanation: Bone marrow aspiration procedure. The posterior superior iliac crest is the preferred site for bone marrow aspiration and biopsy because no vital organs or vessels are nearby. The patient is placed either in the lateral position with one leg flexed or in the prone position.

Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets?

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.

The body responds to infection by increasing the production of white blood cells (WBCs). The nurse knows to evaluate the differential count for the level of __________, the first WBCs to respond to an inflammatory event.

Neutrophils Explanation: Neutrophils, the most abundant type of white blood cell, are the first of the WBCs to respond to infection or inflammation. The normal value is 3,000 to 7,000/cmm (males) and 1,800 to 7,700/cmm (females).

Which is a symptom of severe thrombocytopenia?

Petechiae Explanation: Clients with severe thrombocytopenia have petechiae, which are pinpoint hemorrhagic lesions, usually more prominent on the trunk or anterior aspects of the lower extremities.

Under normal conditions, the adult bone marrow produces approximately 70 billion neutrophils. What is the major function of neutrophils?

Phagocytosis Explanation: The major function of neutrophils is phagocytosis. T lymphocytes are responsible for rejection of foreign tissue and destruction of tumor cells. Plasma cells produce antibodies call immunoglobulin.

Which statement best describes the function of fibrinogen?

Plays a key role in forming blood clots Explanation: Fibrinogen, the largest share of plasma protein, plays a key role in forming blood clots. It can be transformed from a liquid to fibrin, a solid that controls bleeding. Globulins function primarily as immunologic agents by preventing or modifying some types of infectious diseases. On the other hand, albumin helps maintain the osmotic pressure that retains fluid in the vascular compartment.

An older adult patient presents to the physician's office with a complaint of exhaustion. The nurse, aware of the most common hematologic condition affecting the elderly, knows that which laboratory values should be assessed?

RBC count Explanation: A decreased red blood cell count is indicative of anemia, a common condition in older adults that results in fatigue.

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. The nurse

Refuses 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 Blook Bank should then take the necessary steps to correct the name on the label on the unit of blood

Which type of lymphocyte is responsible for cellular immunity?

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 hypersensivity reactions.

When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea, and itching. When urticaria, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction?

Type II (cytolytic, cytotoxic) hypersensitivity reaction Explanation: ABO incompatibility, such as from an incompatible blood transfusion, is a type II hypersensitivity reaction. Transfusions of more than 100 ml of incompatible blood can cause severe and permanent renal damage, circulatory shock, and even death. Drug-induced hemolytic anemia is another example of a type II reaction. A type I hypersensitivity reaction occurs in anaphylaxis, atopic diseases, and skin reactions. A type III hypersensitivity reaction occurs in Arthus reaction, serum sickness, systemic lupus erythematosus, and acute glomerulonephritis. A type IV hypersensitivity reaction occurs in tuberculosis, contact dermatitis, and transplant rejection.

A client comes into the emergency department reporting 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 client states, "I had a partial gastrostomy 2 years ago." Based on this information, the nurse attributes these symptoms to which problem?

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. Clients 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 a smooth, beefy red, enlarged tongue and cranial nerve deficiencies.

A nurse is reviewing a client's morning laboratory results and notes a left shift in the band cells. Based on this result, the nurse can interpret that the client

may be developing an infection. Explanation: Less mature granulocytes have a single-lobed, elongated nucleus and are called band cells. 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 in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.

Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called

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.

An 84-year-old woman is to receive 2 units of packed red blood cells. During the transfusion of the first unit at 125 mL/hour, the client reports shortness of breath 30 minutes into the process. The client exhibits the vital signs shown in the accompanying table. The best nursing intervention is to:

slow the rate of the transfusion and obtain an order for furosemide (Lasix) Explanation: The description is consistent with a client who is experiencing circulatory overload. The nurse is to slow the rate of the transfusion and administer a diuretic. Oxygen is administered with a prescription and for severe dyspnea. This option does not allow for the nurse to slow the transfusion. The nurse would still be administering the blood at the current rate of 125 mL/hour. Diphenhydramine would be prescribed for an allergic reaction. Blood and urine specimens are obtained for acute hemolytic reactions.