Med-Surg: Chapter 33

A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the physician immediately because the client probably is experiencing which problem?

A hemolytic allergic reaction caused by an antigen reaction Hemolytic allergic reactions are fairly common and may cause chills, fever, urticaria, tachycardia, dyspnoea, chest pain, hypotension, and other signs of anaphylaxis a few minutes after blood transfusion begins. Although rare, a hemolytic reaction to mismatched blood can occur, triggering a more severe reaction and, possibly, leading to disseminated intravascular coagulation. A hemolytic reaction to Rh-incompatible blood is less severe and occurs several days to 2 weeks after the transfusion. Bacterial contamination of donor blood causes a high fever, nausea, vomiting, diarrhoea, abdominal cramps and, possibly, shock.

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. 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.

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?

Erythrocytes that are microcytic and hypochromic 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.

A client is hospitalized with sickle cell anemia and the nurse is preparing a teaching plan to review with the client and the client's family. Which interventions should be included?

Never exceed the recommended dosages of analgesics. Dress warmly in cold temperatures. While participating in physical exercise, wear constrictive clothing to support circulation. Dehydration can increase risk of a sickle cell crisis. The client should drink water throughout the day, increasing the amount when exercising or spending time in a hot, dry climate. Avoid extremes of heat and cold. Wear warm clothes outside in cold weather and inside of air-conditioned rooms. Do not swim in cold water. Be cautious at high altitudes; extra oxygen may be needed. Avoid vigorous physical exercise and leg positions or clothing that cause vasoconstriction. Especially avoid exceeding the recommended dosage of narcotic analgesics and avoid self-medicating with illegal substances.

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

megaloblasts. Megaloblasts are abnormally large erythrocytes. Blast cells are primitive white blood cells (WBCs). Mast cells are cells found in connective tissue involved in defense of the body and coagulation. Monocytes are large WBCs that become macrophages when they leave the circulation and move into body tissues.

A 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 for the rest of my life." 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.

A nurse cares for a client suspected of having iron deficient anemia. Which diagnostic test will the nurse expect the health care provider to order in order to definitively diagnose the condition?

Bone marrow aspiration The definitive method of diagnosis for iron deficiency anemia is bone marrow aspiration. The other answer choices may also be used to help with the diagnosis of the condition; however, these are not definitive diagnostic tests.

Which is a symptom of Cooley anemia?

Bronzing of the skin Clients with Cooley anemia exhibit symptoms of severe anemia and a bronzing of the skin, which is caused by hemolysis of erythrocytes. Dyspnea, stomatitis (inflammation of the mouth), and glossitis (inflammation of the tongue) are symptoms of pernicious anemia.

A patient with ESRD is taking recombinant erythropoietin for the treatment of anemia. What laboratory study does the nurse understand will have to be assessed at least monthly related to this medication?

Hemoglobin level When using recombinant erythropoietin, the hemoglobin must be checked at least monthly (more frequently until a maintenance dose is established) and the dose titrated to ensure the hemoglobin level does not exceed 12 g/dL.

A client has a history of sickle cell anemia with several sickle cell crises over the past 10 years. What blood component results in sickle cell anemia?

hemoglobin S Hemoglobin A (HbA) normally replaces fetal hemoglobin (HbF) about 6 months after birth. In people with sickle cell anemia, however, an abnormal form of hemoglobin, hemoglobin S (HbS), replaces HbF. HbS causes RBCs to assume a sickled shape under hypoxic conditions.

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?

Platelet count, prothrombin time, and partial thromboplastin time 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.

A client has hereditary hemochromatosis. Laboratory test results indicate an elevated serum iron level, high transferrin saturation, and normal complete blood count (CBC). It is most important for the nurse to

Remove the prescribed one unit of blood. Treatment for hemochromatosis is phlebotomy or removal of whole blood from a vein to reduce iron. Limiting dietary intake of iron is not an effective treatment. The client needs to perform activities to protect the liver, such as limiting alcohol ingestion. The definitive test for hemochromatosis had been a liver biopsy, but now genetic testing is performed. A liver biopsy could be performed to determine liver damage. However, this does not address the most immediate problem of too high iron.

A client with sickle cell disease is treated for a thrombotic event. Which organs or body systems does the nurse recognize as being at greatest risk for thrombosis in a client with sickle cell disease?

Spleen Lungs Central nervous system Any organ can be the site of a thrombotic event in sickle cell disease; however, the lungs, central nervous system, and the spleen are at greatest risk due to these areas having slower circulation.

A client is prescribed 325 mg/day of oral ferrous sulfate. The nurse includes in client teaching, "Take your iron pill

1 hour before breakfast" Instructions the nurse will provide for the client taking oral ferrous sulfate is to administer the medication on an empty stomach. Instructions also include that there is decreased absorption of iron with food, particularly dairy products. The client is to increase vitamin C intake (fruits, juices, tomatoes, broccoli), which will enhance iron absorption. The client is to also increase foods high in fiber to decrease risk of constipation.

A patient with chronic renal failure is examined by the nurse practitioner for anemia. The nurse knows to review the laboratory data for a decreased hemoglobin level, red blood cell count, and which of the following?

Decreased level of erythropoietin 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.

The nurse is talking with the parents of a toddler who was diagnosed with hemophilia A. The nurse teaches the parents

How to administer factor VIII intravenously at the first sign of bleeding Clients and families are taught to administer factor VIII intravenously. This helps to prevent bleeding episodes. Activities that minimize trauma are allowed for the toddler, and playground activities may place the toddler at risk for increased bleeding. Over-the-counter cold preparations are to be avoided, because they will interfere with platelet aggregation. Nasal packing is avoided, because when the nasal packing is removed, bleeding may occur.

A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?

Obtain the pain medication and delay the bath and position change until the medication reaches its peak. When pain is severe, the nurse delays position changes and bathing until an administered analgesic has reached its peak concentration level and the client is experiencing maximum pain relief. Pain medication should never be delayed to assist in the control of the level of pain. Pain will not be relieved by a bath and clean sheets, only analgesics at this point in the client's illness.

A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?

Pallor, tachycardia, and a sore tongue 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.

In adults, bone marrow is usually aspirated from which area?

Posterior iliac crest 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.

Which of the following vitamins enhance the absorption of iron?

C Vitamin C facilitates the absorption of iron. Therefore, iron supplements should be taken with a glass of orange juice or a vitamin C tablet to maximize absorption.

A client reports feeling tired, cold, and short of breath at times. Assessment reveals tachycardia and reduced energy. What would the nurse expect the physician to order?

CBC Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. A CBC would be ordered.

During the review of morning laboratory values for a client reporting severe fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron deficiency anemia based on which finding?

Low ferritin level concentration The most consistent indicator of iron deficiency anemia is a low ferritin level, which reflects low iron stores. As the anemia progresses, the MCV, which measures the size of the erythrocytes, also decreases. Hematocrit and RBC levels are also low in relation to the hemoglobin concentration.

A client with a diagnosis of pernicious anemia comes to the clinic complaining of numbness and tingling in their arms and legs. What do these symptoms indicate?

Neurologic involvement 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.

You are caring for a client with thalassemia who is being transfused. What is your role during a transfusion?

To closely monitor the rate of administration In a client with thalassemia, when transfusions are necessary, the nurse closely monitors the rate of administration. Assessing for enlargement and tenderness over the liver and spleen, advising rest, or administering vitamin B12 injections are not indicated for thalassemia.

Which of the following describes a red blood cell (RBC) that has pale or lighter cellular contents?

Hypochromic An RBC that has pale or lighter cellular contents is hypochromic. A normocytic RBC is normal or average in size. A microcytic RBC is smaller than normal. Hyperchromic is used to describe an RBC that has darker cellular contents.

An client has pernicious anemia and has been receiving treatment for several years. Which symptom may be confused with another condition in older adults?

dementia Pernicious anemia may be accompanied by a dementia with symptoms similar to Alzheime's disease. Therefore, clients experiencing cognitive changes should be screened because early detection of pernicious anemia is critical to prevent neurologic damage.

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?

Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit 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.

A client is being admitted to the hospital with abdominal pain, anemia, and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him:

onto the bedpan. A client who's dizzy and anemic is at risk for injury because of his weakened state. Assisting him with the bedpan would best meet his needs at this time without risking his safety. The client may fall if walking to the bathroom, left alone to urinate, or trying to stand up.

Which is a symptom of hemochromatosis?

Bronzing of the skin Clients with hemochromatosis exhibit symptoms of weakness, lethargy, arthralgia, weight loss, and loss of libido early in the illness trajectory. The skin may appear hyperpigmented from melanin deposits or appear bronze in color.

A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important?

Immediately stop the transfusion, infuse normal saline solution, call the physician, and notify the blood bank. When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be infused to maintain venous access, and the physician and blood bank should be notified immediately. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock. Because they can cause red blood cell hemolysis, dextrose solutions shouldn't be infused with blood products. Antihistamines are administered for a mild allergic reaction, not a hemolytic reaction.

A client's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC?

"DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs." The inflammatory response initiates the process of inflammation and coagulation. The natural anticoagulant pathways within the body are simultaneously impaired, and the fibrinolytic system is suppressed, allowing a massive amount of tiny clots forms in the microcirculation. As the platelets and clotting factors form microthrombi, coagulation fails. Thus, the paradoxical result of excessive clotting is bleeding. Decline in organ function is usually a result of excessive clot formation (with resultant ischemia to all or part of the organ).

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 physician. What type of anemia is the nurse concerned the co-worker may have?

Iron deficiency anemia People with iron deficiency anemia may crave ice, starch, or dirt; this craving is known as pica.