CH 30 Anemia and other RBC disorders

To prepare for a patient's transfusion of packed red blood cells, the nurse would select which IV solution to use for the procedure?

0.9% normal saline The blood set should be primed before the transfusion with 0.9% sodium chloride, also known as normal saline. It is also used to flush the blood tubing after the infusion is complete to ensure that the patient receives blood that is left in the tubing when the bag is empty. 3% normal saline, Lactated Ringer's and 5% dextrose in water, are not compatible with blood products.

The nurse will begin a patient's transfusion of packed red blood cells at 1030. The nurse would plan to stay in the patient's room until which time?

1045 As part of standard procedure, the nurse remains with the patient for the first 15 minutes after hanging a blood transfusion. Patients who are likely to have a transfusion reaction more often will exhibit signs within the first 15 minutes that the blood is infusing. Ten minutes is not enough time to evaluate for adverse reactions; unless the patient is having an adverse reaction, it is not necessary to remain at the bedside for longer than 15 minutes.

Which potential side effect would the nurse include when teaching a patient about the administration of ferrous gluconate?

2 Constipation Iron supplements, such as ferrous gluconate, reduce peristalsis and result in constipation. Ferrous gluconate does not reduce BP and does not result in hypotension. Ferrous gluconate can cause gastrointestinal bleeding and black, tarry stools. Ferrous gluconate does not cause fluid accumulation in the peritoneal cavity or abdominal swelling.

The nurse would ask which health care team member to assist when checking a unit of packed red blood cells before administration?

Another registered nurse (RN) Before hanging a transfusion, the registered nurse must check the unit with another RN or with a licensed practical (vocational) nurse, depending on agency policy. If there is not another nurse available, a health care provider could check the blood with the nurse. The unit secretary, physician's assistant, and UAP are not licensed to perform this duty.

The nurse understands that with repeated episodes of sickling, which organ is most affected?

Lungs With repeated episodes of sickling, there is gradual involvement of all body systems and organs, especially the spleen, lungs, kidneys, and brain. Organs that have a need for large amounts of O2, like the lungs, are most often affected and form the basis for many of the complications of sickle cell disease (SCD). Although the liver, heart, and stomach may be affected, they are less so when compared to the lungs.

The nurse provides discharge teaching to a patient with sickle cell disease (SCD). Which statements made by the patient indicate understanding of the teaching? Select all that apply.

"I should avoid high altitudes." "I should start screening for retinopathy at age 10." Patients with SCD should avoid crises by avoiding activities that cause hypoxia. High altitudes can increase the risk for the development of hypoxia. Regular screenings for retinopathy are recommended. The patient should not drink orange juice too often because orange juice is rich in vitamin C. Eating uncooked seafood increases the risk of infection; this type of product is rich in iron and should be avoided. The pneumococcal injection is recommended to prevent infection.

Which erythrocyte characteristic would the nurse expect to see in the laboratory findings for a patient who has experienced acute blood loss?

Normocytic, normochromic erythrocytes are seen in patients with acute blood loss following an accident. Microcytic, hypochromic erythrocytes are seen in patients with iron-deficiency anemia, vitamin B6 deficiency, copper deficiency, thalassemia, or lead poisoning. Megaloblastic erythrocytes are seen in patients with vitamin B12 deficiency, folic acid deficiency, or liver disease.

Which condition is characterized by the presence of a high percentage of hemoglobin S (Hgb S) in the erythrocytes?

Sickle cell disease Sickle cell disease is characterized by the presence of a high percentage of Hgb S in the erythrocytes. Thalassemia occurs due to the absence of reduced globulin protein. Aplastic anemia is a disease characterized by pancytopenia in which all the blood cell types decrease. Acquired hemolytic anemia results from hemolysis of red blood cells (RBCs) from extrinsic factors. It is characterized by increased mean corpuscular volume (MCV), reticulocytes, and bilirubin.

Which finding supports the nurse's conclusion that a patient has pernicious anemia?

Smooth, beefy-red tongue Pernicious anemia is characterized by the presence of abdominal pain and a smooth, beefy-red tongue. Platelet function is reduced in the patient with leukemia; therefore bleeding from the gums is associated with leukemia. The presence of spoon-shaped, concave nails and fissures in the corners of the mouth is associated with iron-deficiency anemia.

When a patient is prescribed iron tablets for the treatment of anemia, which measures ensure maximum absorption? Select all that apply.

Taking the tablet with orange juice Taking the tablet an hour before meals Taking iron tablets an hour before food ensures maximum absorption because iron will not get bound to food. When iron binds with food, absorption of iron falls. Orange juice and ascorbic acid enhance iron absorption. Taking iron tablets with food can reduce iron absorption. Taking iron tablets before or after exercise does not affect absorption.

A patient's laboratory reports show a low mean corpuscular volume (MCV) and a high reticulocyte count. The nurse suspects which condition?

Thalassemia In thalassemia, a low MCV and a high reticulocyte count are observed. In hemolytic anemia, a normal MCV and increased reticulocytes are found. In sickle cell anemia, a normal MCV and low reticulocyte count are seen. An increased MCV and normal or low reticulocyte count occur due to a folic acid deficiency.

The nurse is providing discharge instructions to a patient who has anemia secondary to acute blood loss. Which instruction would the nurse include in the discharge teaching?

"Now that the blood loss is controlled and as your blood volume is replaced, the anemia generally corrects itself, so no long-term treatment is needed." Anemia caused by acute blood loss generally resolves itself once the source of the bleeding is identified and controlled and blood/fluid volume is replaced. It is incorrect to tell the patient he or she will need supplements for the rest of his or her life, that dietary changes will be necessary for the next year or two, or that several supplements are necessary to prevent recurrence.

Which laboratory report findings support the nurse's conclusion that a patient has thalassemia major? Select all that apply.

1, 2, 3 Thalassemia major is characterized by the presence of increased bilirubin levels, serum iron levels, and reticulocyte level. Thalassemia major is also characterized by the presence of decreased mean corpuscular volume and total iron-binding capacity.

The nurse assesses a patient who has severe anemia and expects to find which manifestations? Select all that apply.

1, 2, 4, 5 Vertigo Dyspnea at rest Jaundice and pruritus Glossitis and smooth tongue In severe anemia (Hgb less than 6 g/dL [60 g/L]), the patient has many clinical manifestations involving multiple body systems, including vertigo, dyspnea at rest, jaundice and pruritus, and glossitis and smooth tongue. The patient will not have sensitivity to heat, but rather a sensitivity to cold.

The nurse suspects that a patient has polycythemia vera based on which findings in the patient's laboratory reports? Select all that apply.

1, 3, 4, 6 Increased cobalamin levels Increased hemoglobin levels Increased red blood cell levels Increased white blood cell levels Polycythemia vera has increased cobalamin and hemoglobin levels, as well as the presence of increased red blood cell and white blood cell levels. Elevated levels of histamine and blood platelet count are seen in patients with polycythemia vera.

The nurse would instruct the patient about which side effects of oral iron supplements? Select all that apply.

3, 4, 5 Heartburn Black stools Constipation Because the gastrointestinal (GI) tract excretes excess iron, the primary side effects of oral iron preparations are heartburn, black stools, and constipation. Anorexia is not an expected side effect. Red stool is not a side effect of iron preparation but can be caused by the presence of fresh blood in the stools due to bleeding from hemorrhoids or irritable bowel syndrome.

A patient is to receive cobalamin (vitamin B12) 1,000 mcg by mouth (PO). The pharmacy issues 250-mcg tablets. Which number of tablets would the nurse administer to the patient?

4 tablets Using ratio and proportion, multiply 250 by x and multiply 1000 × 1 to yield 250x = 1000. Divide 1000 by 250 to yield four tablets.

Which condition may cause a patient to develop anemia due to decreased hemoglobin synthesis?

Iron deficiency may cause anemia due to decreased hemoglobin synthesis. Leukemia may cause anemia due to a decreased number of red blood cell (RBC) precursors. Cobalamin deficiency may result in anemia due to defective deoxyribonucleic acid (DNA) synthesis. G6PD enzyme deficiency is hereditary and causes increased RBC destruction (hemolytic anemias).

A patient that is receiving treatment for thalassemia shows evidence of hemolysis. The nurse anticipates a prescription for which supplementation?

Folic acid Folic acid is given if there is any evidence of hemolysis in patients with thalassemia. Zinc supplementation is required in patients with thalassemia after chelation therapy because zinc levels may decline. Vitamin B12 supplementation is required for patients with megaloblastic anemias. Ascorbic acid supplementation may be needed during chelation therapy in patients receiving treatment for thalassemia because it increases urinary excretion of iron.

Which condition results in anemia due to synthesis of defective deoxyribonucleic acid (DNA) in the body?

Folic acid deficiency Folic acid deficiency can cause the synthesis of defective DNA and result in anemia. A decreased number of red blood cell precursors results in anemia in patients with myelodysplasia and Fanconi syndrome. Increased red blood cell destruction can result in anemia in patients with G6PD enzyme deficiency.

The nurse would take which action to ensure patient safety when administering a unit of packed red blood cells (PRBCs)?

Have a second registered nurse check the identifying information on the unit of blood against the identification bracelet and blood-bank identification bracelet. The patient's identifying information (name, date of birth, medical record number) on the identification bracelet should match exactly the information on the blood-bank tag that has been placed on the unit of blood. A second registered nurse should perform this check. If any information does not match, the transfusion should not be hung because of possible error and risk to the patient. Blood tubing, not primary tubing, is needed for blood transfusion and should not be administered as a secondary infusion. The nurse should remain with the patient for 15 minutes following initiation of transfusion.

The nurse reviews a patient's assessment findings, which include arthralgia, liver enlargement, and total body iron level of 70 g. The nurse would anticipate providing care related to which condition?

Hemochromatosis The normal range of total body iron is 2 to 6 g, and its concentration exceeds 50 g in case of hemochromatosis. Fatigue, arthralgia, abdominal pain, weight loss, and enlarged liver and spleen are the clinical manifestations of hemochromatosis. Polycythemia is characterized by laboratory manifestations such as elevated hemoglobin and red blood cell (RBC) count, low to normal erythropoietin, elevated white blood cell (WBC) count, platelet, uric acid, and cobalamin levels. The clinical manifestations include headaches, vertigo, dizziness, tinnitus, and visual disturbances. In patients with sickle cell disease, the peripheral blood smear will show sickled cells and abnormal reticulocytes. The patient may have elevated serum bilirubin levels and bone and joint deformities. In patients with iron-deficiency anemia, the laboratory findings indicate a low total body iron and hemoglobin levels along with clinical manifestations such as glossitis, cheilitis, and pallor.

The nurse reviews documentation of assessment findings of a patient with severe anemia. Which assessment finding would the nurse question?

Hyperpigmentation Common integumentary changes observed in anemia include pallor, pruritus, and jaundice. Pallor results from reduced amounts of hemoglobin and reduced blood flow to the skin. Pruritus occurs because of increased serum and skin bile salt concentration. Jaundice occurs when hemolysis of red blood cells (RBCs) results in an increased concentration of serum bilirubin. Hyperpigmentation is usually not associated with anemia.

A patient has a hemoglobin level of 11 g/dL. The nurse determines that the patient has which level of severity of anemia?

In mild anemia, hemoglobin is in the range of 10-12 g/dL. In severe anemia, it is less than 6 g/dL. Aplastic anemia refers to a type of anemia caused by a decrease in red blood cell precursors. It does not refer to the severity of anemia. In moderate anemia, the hemoglobin it is in the range of 6-10 g/dL. Hemoglobin above 12 g/dL is considered normal (no anemia).

The nurse recalls that hemolytic anemia can be caused by which extrinsic factors?

Infectious agent Infectious agents, such as malaria, are extrinsic factors that can lead to acquired hemolytic anemias. Abnormal hemoglobin, such as sickle cell disease, and enzyme deficiencies are intrinsic factors that lead to hereditary (intrinsic) hemolytic anemias. Membrane abnormalities, such as paroxysmal nocturnal hemoglobinuria, cause increased red blood cell (RBC) destruction and are hereditary (intrinsic) factors.

Which assessment finding would the nurse associate with severe anemia?

Pallor The integumentary finding of pallor is associated with severe anemia. Gastrointestinal diarrhea is not associated with anemia. Cardiovascular palpitations are associated with mild anemia. Pulmonary exertional dyspnea is associated with mild anemia.

A patient's laboratory report reveals a hemoglobin (Hgb) level of 11 g/dL. The nurse expects to observe which clinical manifestation?

Palpitations An Hgb range of 10 to 12 g/dL indicates mild anemia. Therefore the patient with an Hgb of 11 g/dL may experience palpitations. Glossitis is one of the manifestations of severe anemia in which the patient would have an Hgb level below 6 g/dL. Exertional dyspnea is seen in patients with mild anemia. However, dyspnea at rest is a manifestation of severe anemia. Roaring in the ears is seen in patients with moderate anemia whose Hgb values range between 6 and 10 g/dL.

Which role does folic acid play in erythropoiesis?

Promotes red blood cell (RBC) maturation Folic acid promotes maturation of RBCs. Ascorbic acid aids in the absorption of iron. Iron and pyridoxine promote hemoglobin synthesis. Copper helps to mobilize iron from tissue to plasma.

The nurse assesses a patient with pernicious anemia and expects to find which classic sign of this condition?

Red, beefy tongue The decreased absorption of vitamin B12 resulting from a lack of intrinsic factor causes a decrease in hemoglobin, hematocrit, and red blood cells. A smooth, red, enlarged or "beefy" appearance of the tongue may also be seen. Intrinsic factor is produced by the parietal cells of the stomach lining and is required to absorb vitamin B12 from the intestines. Causes of decreased intrinsic factor production include surgical alterations such as gastrectomy and autoimmune disease. Diarrhea, indigestion, and flushed skin appearance are not signs specifically associated with pernicious anemia.