Chapter 32
A client verbalizes fear of infection from a blood transfusion. What is the nurse's best response?
"Every unit of donated blood is typed and tested for antibodies to infections."
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."
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."
A preoperative client is discussing blood donation with the nurse. Which statement by the client indicates to the nurse the need for further teaching?
"My family will donate blood, because it's safer."
A nurse cares for a client with megaloblastic anemia who had a total gastrectomy three years ago. What statement will the nurse include in the client's teaching regarding the condition?
"The condition is likely caused by a vitamin B12 deficiency."
A nurse is caring for a client who will undergo total knee replacement and will have an autologous transfusion. Which statement will the nurse include when teaching the client about the transfusion?
"You typically donate blood 4 to 6 weeks before the surgery."
The nurse begins a routine blood transfusion of packed red blood cells (PRBCs) at 1100. To ensure client safety, the unit of blood should be completely transfused by what time?
1500
Which client is not a candidate to be a blood donor according to the American Red Cross?
26-year-old female with hemoglobin 11.0 g/dL
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
A nurse is preparing a dose of furosemide for an older adult with heart failure. The health care provider orders furosemide 1 mg/kg to be given intravenously. The client weighs 50 kg. The concentration of the drug is 40 mg/4mL (10 mg/mL). How many milliliters would the nurse administer? Record your answer using a whole number.
5 mL
Place the steps of fibrin clot breakdown in correct order.
Activation of plasminogen Formation of plasmin Digestion of fibrinogen and fibrin Release of fibrin degradation products
A client with Hodgkin disease had a bone marrow biopsy yesterday and reports aching at the biopsy site, rated a 5 (on a 1-10 scale). After assessing the biopsy site, which nursing intervention is most appropriate?
Administer acetaminophen 500 mg po, as ordered
The nurse is obtaining the health history of a client suspected of having a hematological condition. The nurse notes the client has a history of alcohol abuse. Which clinical presentation is related to alcohol consumption?
Anemia
The physician performs a bone marrow biopsy from the posterior iliac crest on a client with pancytopenia. What intervention should the nurse perform after the procedure?
Apply pressure over the site for 5-7 minutes
Which type of leukocyte contains histamine and is an important part of hypersensitivity reactions?
Basophils
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
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.
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
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.
A client receiving a blood transfusion reports 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 health care provider?
Ensure there is an oxygen delivery device at the bedside.
A client with severe anemia is admitted to the hospital. Because of religious beliefs, the client is refusing blood transfusions. The nurse anticipates pharmacologic therapy with which drug to stimulate the production of red blood cells?
Epoetin alfa
A client with chronic kidney disease has chronic anemia. What pharmacologic alternative to blood transfusion may be used for this client?
Erythropoietin
A patient is undergoing platelet pheresis at the outpatient clinic. What does the nurse know is the most likely clinical disorder the patient is being treated for?
Essential thrombocythemia
A client wants to donate blood before his or her abdominal surgery next week. What should be the nurse's first action?
Explain the time frame needed for autologous donation.
Which term describes the percentage of blood volume that consists of erythrocytes?
Hematocrit
Which term refers to the percentage of blood volume that consists of erythrocytes?
Hematocrit
A client complains of extreme fatigue. Which system should the nurse suspect is most likely affected?
Hematological
A nurse is caring for a patient who has had a bone marrow aspiration with biopsy. What complication should the nurse be aware of and monitor the patient for?
Hemorrhage
Splenic sequestration is diagnosed in a client admitted with splenomegaly. What is the priority of care for this client?
Hypovolemia
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 reason?
Lack of erythropoietin
The nurse is providing health education to an older adult client who has low red blood cell levels. To promote red blood cell production, the nurse should encourage intake of what foods? Select all that apply.
Leafy green vegetables Nuts and seeds Lean meats
Which blood cell type is matched correctly with its function?
Leukocyte: Fights infection
Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following?
Liver
Which term refers to a form of white blood cell involved in immune response?
Lymphocyte
Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets?
Myeloid stem cell
The body responds to infection by increasing the production of white blood cells (WBCs). The nurse should evaluate the differential count for what type of WBCs, which are the first WBCs to respond to an inflammatory event?
Neutrophils
Under normal conditions, the adult bone marrow produces approximately 70 billion neutrophils. What is the major function of neutrophils?
Phagocytosis
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.
Popliteal Inguinal Submental Neck
An older adult client presents to the health care provider's office and reports exhaustion. The nurse, aware of the most common hematologic condition affecting the elderly, knows that which laboratory values should be assessed?
RBC count
The nurse is working at a blood donation clinic. What teaching should the nurse provide to the donor immediately after blood donation?
Remain for observation after eating and drinking.
A nurse cares for several mothers and babies in the postpartum unit. Which mother does the nurse recognize as being most at risk for a febrile nonhemolytic reaction?
Rh-negative mother; Rh-positive child
A nurse is transfusing whole blood to a client with impaired renal function. During the transfusion, the client tells the nurse, "I feel very short of breath all of a sudden." What is the nurse's primary action?
Stop the infusion.
The nurse began transfusing the first unit of packed red blood cells (PRBCs) fifteen minutes ago. The client reports shortness of breath, nausea, and is restless. What is the nurse's priority action?
Stop the infusion.
Place the following steps in order when determining the type and severity of a transfusion reaction. Use all options.
Stop the transfusion. Assess the client. Notify the health care provider. Notify the blood bank. Send the tubing and container to the blood bank.
Which type of lymphocyte is responsible for cellular immunity?
T lymphocyte
The health care provider believes that the client has a deficiency in the leukocyte responsible for cell-mediated immunity. What should the nurse check the WBC count for?
T lymphocytes
The nurse is administering a blood transfusion to a client over 4 hours. After 2 hours, the client reports chills and has a fever of 101°F, an increase from a previous temperature of 99.2°F. What does the nurse recognize is occurring with this client?
The client is having a febrile nonhemolytic reaction.
The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells?
The kidneys sense low oxygen levels in the blood and produce erythropoietin, stimulating the bone marrow to produce more red blood cells.
Place the order of the steps of primary hemostasis in correct order.
The severed blood vessel constricts. The circulating platelets aggregate at the site and adhere to the vessel. An unstable hemostatic plug is formed. Circulating inactive clotting factors convert to active forms.
While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client?
Use an electric razor when assisting client with shaving.
The client is to receive a unit of packed red blood cells. What is the nurse's first action?
Verify that the client has signed a written consent form.
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
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.
The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level?
Decreased oxygen level.
A nurse cares for an older adult client with acute myeloid leukemia (AML). What concept does the nurse understand leads to the increased risk of an older adult acquiring myeloid malignancies such as AML?
Older adults acquire damage to the DNA of stem cells over time.
Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called
megaloblasts.
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
A nurse cares for a client with myelodysplastic syndrome who requires frequent PRBC transfusions. What blood component does the nurse recognize as being most harmful if accumulated in the tissues due to chronic blood transfusions?
Iron
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
The physician orders a transfusion with packed red blood cells (RBCs) for a client 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?
Verify the client's identity according to hospital policy
A nurse is assigned to care for a patient with ascites, secondary to cirrhosis. The nurse understands that the fluid accumulation in the peritoneal cavity results from a combination of factors including an alteration in oncotic pressure gradients and increased capillary permeability. Therefore, the nurse monitors the serum level of the plasma protein responsible for maintaining oncotic pressure, which is:
Albumin.
