Chapter 33: Hematologic Disorders

OTHER 29. A nurse plans the interventions to prepare a patient for a bone marrow aspiration. (Place the options in the correct sequence. Separate letters by a comma and space as follows: A, B, C, D.) a. Assist the patient to lie on his or her abdomen and drape the hip and lower limbs. b. Confirm the presence of laboratory personnel to stain the specimen. c. Apply a pressure dressing and help the patient lie on his or her back. d. Ensure that a signed permission form is obtained. e. Explain that the procedure will take about 30 minutes.

ANS: E, D, A, B, C The appropriate sequence is the following: (1) explain the procedure; (2) when the patient indicates an understanding, obtain a signed permission form; (3) assist the patient to lie on his or her abdomen and drape the hip and lower extremities; (4) confirm the presence of laboratory personnel to stain the specimen; and (5) apply a pressure dressing and help the patient lie on his or her back. DIF: Cognitive Level: Application REF: p. 628 OBJ: 3 TOP: Bone Marrow Aspiration Preparation KEY: Nursing Process Step: Implementation MSC:

7. A nurse is taking the history of a patient who has come in for evaluation of large areas of purpura on her limbs. The patient reports using alternative therapy for her menopausal symptoms. What alternative therapy is most likely responsible for the patient's symptoms? a. Black cohosh b. Valerian c. Lavender d. Rosemary

ANS: A Black cohosh interferes with blood clotting. DIF: Cognitive Level: Comprehension REF: p. 627 OBJ: 5 TOP: Alternative Remedies KEY: Nursing Process Step: Assessment MSC:

25. At 1000 a nurse receives 2 units of blood for a patient to be transfused. What is the most appropriate nursing action? a. Set up 1 unit for the infusion to start by 1030 and send the other unit back until the first one has infused b. Set up both units to infuse at the same time and to start at 1100. c. Set up one unit for infusion and place the other in the refrigerator for the later infusion. d. Send both units back and ask for a reissue of 1 unit only.

ANS: A Blood must be started within 30 minutes of its receipt after it has been checked by two licensed staff members. In many settings, licensed practical nurses do not start the blood but can set up the infusion. The best option is to send the second unit back immediately, with an explanation that it will be called for later. One unit of blood usually takes about 2 to 4 hours to infuse. DIF: Cognitive Level: Application REF: p. 631 OBJ: 4 TOP: Transfusion Protocol KEY: Nursing Process Step: Implementation MSC:

23. A nurse is assessing a patient 20 minutes after a bone marrow biopsy. Which statement by the patient is cause for the most concern? a. "There is fresh blood on my dressing." b. "I am thirsty." c. "My hip feels bruised where they stuck the needle." d. "I had a sharp pain in my leg when they pulled the needle out."

ANS: A Fresh blood on the pressure dressing 20 minutes after the aspiration needs to be addressed. Usually, redressing with a pressure dressing and an ice pack is sufficient. Feelings of bruising and pain on extraction are to be expected. Thirst is of no clinical significance. DIF: Cognitive Level: Application REF: p. 628 OBJ: 3 TOP: Diagnostic Tests KEY: Nursing Process Step: Implementation MSC:

2. Which is considered an approximate normal hematocrit value? a. Three times the hemoglobin value b. The same as the hemoglobin value c. Four times lower than the red blood cell count d. Same as the red blood cell count

ANS: A Hematocrit is approximately three times the hemoglobin value. DIF: Cognitive Level: Knowledge REF: p. 627 OBJ: 3 TOP: Normal Laboratory Values KEY: Nursing Process Step: Assessment MSC:

10. Which foods should a nurse include in a nutrition teaching plan for a patient with iron-deficiency anemia? a. Beans and dried fruit b. Apples and white rice c. Yogurt and cooked carrots d. Yellow squash and tortillas

ANS: A Iron-rich foods include beans, dried fruit, liver, red meat, fish, and whole-grain breads. DIF: Cognitive Level: Comprehension REF: p. 635 OBJ: 6 TOP: Iron-Deficiency Anemia KEY: Nursing Process Step: Implementation MSC:

11. Based on a nursing assessment, what is an appropriate nursing diagnosis for a patient with hemophilia? a. Acute pain related to bleeding into closed spaces b. Impaired gas exchange related to decreased oxygen to the cells c. Excess fluid volume related to increased fluid within the cells d. Hypothermia related to inability to produce heat

ANS: A Patients with hemophilia have severe pain caused by bleeding into the joints. DIF: Cognitive Level: Application REF: p. 640 OBJ: 4 TOP: Hemophilia KEY: Nursing Process Step: Nursing Diagnosis MSC:

15. To what level should the platelet count rise when the patient with a platelet count of 20,000/mm3 receives 1 unit of platelets? a. 25,000 to 30,000/mm3 b. 35,000 to 40,000/mm3 c. 45,000 to 50,000/mm3 d. 55,000 to 100,000/mm3

ANS: A Platelet transfusions are given when the platelet count falls below 20,000/mm3. One unit is expected to raise the count by 5000 to 10,000/mm3. DIF: Cognitive Level: Knowledge REF: p. 630 OBJ: 3 TOP: Platelet Transfusion KEY: Nursing Process Step: Assessment MSC:

17. A 35-year-old man is examined in an urgent care clinic. His presenting symptoms suggest polycythemia vera. Which extreme laboratory value would confirm this possible diagnosis? a. High hemoglobin level b. Low white cell count c. Low platelet count d. High iron level

ANS: A The symptoms of polycythemia vera are extremely high hemoglobin and hematocrit values because of the excessive production of red blood cells. Patients with polycythemia vera have 1 pint of blood taken from them until the blood values become more normal. The blood is collected as it would be for a blood donation, but it cannot be used for transfusion purposes. DIF: Cognitive Level: Comprehension REF: p. 632-633 OBJ: 5 TOP: Polycythemia Vera KEY: Nursing Process Step: Assessment MSC:

20. At the end of a shift, a nurse documents the effectiveness of parent teaching concerning the transmission of hemophilia. Which statement by the mother would best indicate an accurate parental perception? a. "Hemophilia is a genetic disorder, and I am a carrier, although I do not have the disease." b. "My son developed hemophilia because I had measles while I was pregnant." c. "Because my husband isn't affected by the disease, our daughter will not be a carrier." d. "I know it is not necessary to have my two daughters tested for the disease."

ANS: A Women carry the trait and pass it on to their sons. DIF: Cognitive Level: Comprehension REF: p. 639 OBJ: 5 TOP: Hemophilia KEY: Nursing Process Step: Evaluation MSC:

5. A patient receiving Epogen asks how soon an increase in the red blood cell count will occur. When should the nurse say that the initial increase in red blood cells should be seen? a. 2 days b. 1 week c. 10 days d. 2 weeks

ANS: D Epoetin alfa (Epogen) stimulates the bone marrow to produce more red blood cells in approximately 2 weeks. DIF: Cognitive Level: Comprehension REF: p. 634 OBJ: 6 TOP: Colony-Stimulating Medication KEY: Nursing Process Step: Planning MSC:

19. A nurse is completing an initial assessment on a new patient being seen in the hospital clinic. The presentation of this female patient includes vague symptoms of tiredness and large areas of ecchymosis. Which question is most important for the nurse to ask? a. "Are you allergic to anything?" b. "Do your gums easily bleed?" c. "How many hours do you sleep?" d. "How frequent are your periods?"

ANS: B Bleeding gums are indicative of general bleeding tendencies. Sleep and frequency of menstrual periods are not significant, but the heaviness of the period is significant. History can reveal information pertinent to assisting the physician in making a diagnosis. DIF: Cognitive Level: Application REF: p. 625 OBJ: 2 TOP: Assessment of Patients with Hematologic Disorders KEY: Nursing Process Step: Assessment MSC:

24. A nurse caring for a patient with crushing injuries from an automobile accident notes that the patient is bleeding profusely from the nose, mouth, and rectum, as well as from the injuries. What should the nurse suspect as the cause of this patient's bleeding? a. Hemophilia b. Disseminated intravascular coagulation (DIC) c. Leukemia d. Thrombocytopenia

ANS: B DIC occurs in massive crushing injuries, burns, and allergic responses. The body's clotting ability is exhausted because of its attempt to repair so many areas with coagulation. When the platelet supply is gone, the clotting ability is lost, and massive hemorrhaging occurs. DIF: Cognitive Level: Analysis REF: p. 639 OBJ: 4 TOP: DIC KEY: Nursing Process Step: Assessment MSC:

26. A nurse is giving iron dextran intramuscularly (IM). Why should the nurse implement the Z-track method? a. Makes the injection less painful b. Prevents staining of the skin c. Prevents postinjection pain d. Allows another injection to be given at the same location

ANS: B The Z-track method only ensures that no iron will be staining the skin after injection. The amount of pain is the same and, after all IM injections, the needle is cleaned on withdrawal. Injections are never given at recent injection sites. DIF: Cognitive Level: Comprehension REF: p. 634 OBJ: 6 TOP: Z-Track Method KEY: Nursing Process Step: Implementation MSC:

4. A nurse is caring for a patient receiving a transfusion and assesses that the patient is wheezing and is complaining of back pain. What nursing action should take place after stopping the transfusion? a. Discontinue the intravenous (IV) transfusion. b. Notify the charge nurse. c. Administer heparin. d. Raise the patient's head.

ANS: B The charge nurse should be notified immediately after the transfusion is stopped. The charge nurse will notify the physician and the laboratory or blood bank. The head of the bed should be raised to aid in respiration, and oxygen should be administered in high doses. The blood tubing and bag should not be discarded because the blood bank will want it to check the accuracy of the typing. DIF: Cognitive Level: Application REF: p. 632 OBJ: 4 TOP: Blood Transfusion Reactions KEY: Nursing Process Step: Implementation MSC:

9. What is the rationale for administering injections of vitamin B12 to patients with pernicious anemia? a. The patient's body does not normally manufacture enough vitamin B12. b. The patient may lack the intrinsic factor necessary for vitamin B12 absorption. c. Vitamin B12 is found in very small quantities in the patient's body. d. Vitamin B12 is a mineral necessary to aid in the formation of strong bones.

ANS: B The patient with pernicious anemia lacks the intrinsic factor, found in the stomach, which is essential for vitamin B12 absorption. DIF: Cognitive Level: Comprehension REF: p. 635 OBJ: 5 TOP: Pernicious Anemia KEY: Nursing Process Step: Evaluation MSC:

18. A 52-year-old man has a diagnosis of aplastic anemia. What information in the patient history is pertinent to this diagnosis? a. Long family history of cancer b. Regular blood donor c. 25-year employee in a chemical plant d. Gain of 5 lb in the last 2 years

ANS: C Exposure to toxic chemicals can cause aplastic anemia. DIF: Cognitive Level: Analysis REF: p. 633 OBJ: 5 TOP: Aplastic Anemia KEY: Nursing Process Step: Assessment MSC:

27. What is the major difference between fresh-frozen plasma (FFP) and cryoprecipitate (CPP)? a. FFP contains more albumin. b. FFP has a longer infusion time. c. FFP contains no platelets. d. FFP has a very high probability of causing an allergic reaction.

ANS: C FFP contains no platelets. DIF: Cognitive Level: Knowledge REF: p. 631 OBJ: 5 TOP: FFP versus CPP KEY: Nursing Process Step: Implementation MSC:

13. A newborn infant has developed significant jaundice and has a positive Coombs test result resulting from high levels of bilirubin. What should a nurse be aware that these symptoms may indicate? a. Aplastic anemia b. Hemophilia c. Hemolytic anemia d. Sickle cell anemia

ANS: C Newborns can develop hemolytic anemias resulting from blood incompatibility to their mother. These are typical signs of hemolytic anemia in the newborn. DIF: Cognitive Level: Comprehension REF: p. 634-635 OBJ: 5 TOP: Hemolytic Anemia KEY: Nursing Process Step: Assessment MSC:

21. What should a nurse be careful to observe for when assessing a patient with thrombocytopenia? a. Distended neck veins and skin discoloration b. Discoloration of the nails and sclera c. Petechiae on the skin and bleeding gums d. Enlarged thyroid gland and excitability

ANS: C Symptoms of thrombocytopenia include petechiae, purpura, bleeding gums, and epistaxis. DIF: Cognitive Level: Analysis REF: p. 638 OBJ: 5 TOP: Thrombocytopenia KEY: Nursing Process Step: Assessment MSC:

28. What medical history information is significant to potential bleeding problems? (Select all that apply.) a. Drinks two glasses of wine a day b. Eats red meat three times a week c. Takes nonsteroidal antiinflammatory drugs (NSAIDs) for the relief of arthritic pain four times a day d. Has hepatitis B e. Had a cardiac valve replaced 6 months earlier

ANS: C, D, E NSAIDs and liver disorders enhance the probability of bleeding. The valve replacement of a few months earlier suggests that the patient is using anticoagulant drugs. DIF: Cognitive Level: Comprehension REF: p. 625 OBJ: 2 TOP: Factors Predisposing to Bleeding Tendency KEY: Nursing Process Step: Assessment MSC:

6. What happens to the sickle-shaped red blood cells during a sickle cell crisis? a. Rupture b. Production of hemoglobin S c. Interference with blood production d. Obstruction of major arteries

ANS: D Circulatory obstruction causes severe pain in patients with sickle cell anemia, which is the major symptom in sickle cell crisis. The hemoglobin S does not, in itself, cause the crises until the cells obstruct a vessel. DIF: Cognitive Level: Comprehension REF: p. 635 OBJ: 5 TOP: Sickle Cell Anemia KEY: Nursing Process Step: Assessment MSC:

22. A nurse is helping prepare a nursing care plan for a 90-lb, 82-year-old woman with iron-deficiency anemia with a hemoglobin of 5.2. What is the most appropriate nursing diagnosis? a. Impaired tissue integrity related to immobility b. Disturbed body image related to weight loss c. Anxiety related to an unfamiliar hospital environment d. Activity intolerance related to fatigue

ANS: D Fatigue and activity intolerance are common complaints of patients with hematologic disorders. DIF: Cognitive Level: Application REF: p. 635 OBJ: 6 TOP: Hematologic Nursing Diagnosis KEY: Nursing Process Step: Nursing Diagnosis MSC:

8. What information should a nurse be sure to include when preparing discharge plans for a patient recently diagnosed with pernicious anemia? a. Adding daily high-fat, low-fiber supplements b. Adding a rigorous daily workout c. Avoiding prolonged exposure to direct sunlight d. Providing sufficient rest periods throughout the day

ANS: D Fatigue and weakness are seen in all anemias. DIF: Cognitive Level: Application REF: p. 635 OBJ: 6 TOP: Pernicious Anemia KEY: Nursing Process Step: Planning MSC:

12. A child with sickle cell anemia is prescribed the drug hydroxyurea. What effect from the drug should the patient expect to have? a. Increase energy b. Decrease cardiomegaly c. Clean out obstructed vessels d. Produce a hemoglobin that resists sickling

ANS: D Hydroxyurea produces a hemoglobin that resists sickling. DIF: Cognitive Level: Comprehension REF: p. 636 OBJ: 3 TOP: Hydroxyurea KEY: Nursing Process Step: Implementation MSC:

16. When a nurse is preparing to give ferrous sulfate (Feosol) to a home health care patient, what is the most appropriate nursing action to implement? a. Mix the drug with a high-protein milkshake. b. Give it undiluted with a small snack. c. Mix it with coffee or cola to disguise the bitter taste. d. Dilute it and offer through a straw and a few crackers.

ANS: D Patients should avoid taking iron with milk or caffeine because both inhibit drug absorption. The liquid form of the drug is offered with food in a diluted form through a straw to prevent staining the teeth. DIF: Cognitive Level: Application REF: p. 634 OBJ: 6 TOP: Administration of Feosol KEY: Nursing Process Step: Implementation MSC:

14. A 3-year-old African American child is diagnosed with sickle cell anemia. The parents know that sickle cell anemia is hereditary but do not understand why their child has the disease because neither of them has it. What is the most accurate information to provide? a. At least one of the parents has to have the disease. b. Only one parent has to have the disease or the trait. c. Someone in previous generations had the disease. d. Both parents were carriers of the sickle cell trait.

ANS: D Sickle cell anemia is a genetic disease carried by the recessive genes of both parents, who will not exhibit any symptoms of the disease. DIF: Cognitive Level: Comprehension REF: p. 636 OBJ: 5 TOP: Anemia KEY: Nursing Process Step: Implementation MSC:

1. What should be a major focus in a teaching plan for a teenager with sickle cell anemia? a. Limit tobacco use to no more than two cigarettes a day. b. Eat foods high in iron and vitamin B. c. Maintain environmental temperature at 65° F to 68° F. d. Maintain adequate hydration.

ANS: D The maintenance of adequate fluid intake (4-6 L/day) prevents hemoconcentration. The use of alcohol and tobacco are contraindicated for the patient with sickle cell anemia as the cause vasoconstriction. Warm environments are more therapeutic as warm environments do not cause vasoconstriction. DIF: Cognitive Level: Application REF: p. 638 OBJ: 6 TOP: Sickle Cell Anemia KEY: Nursing Process Step: Planning MSC:

3. A nurse is caring for a patient who is having radiation treatment for cancer. How many days after the start of radiation should the nurse know that the threat of thrombocytopenia exists? a. 2 b. 5 c. 9 d. 12

ANS: D Thrombocytopenia becomes a nursing concern 10 to 14 days after therapy has begun. This concern is true for radiation and chemotherapy. DIF: Cognitive Level: Knowledge REF: p. 638 OBJ: 6 TOP: Thrombocytopenia KEY: Nursing Process Step: Assessment MSC: