Ch. 32: Assessmetn of Hematologic Function & Treatment Modalities
The client's CBC with differential reveals small-shaped hemoglobin molecules. The nurse expects to administer which medication to this client? Iron Vitamin B12 Folate Fresh frozen plasma
Correct response: 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.
Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following? Liver Pancreas Kidney Large intestine
Correct response: Liver Explanation: Albumin is produced by the liver. Albumin is not produced in the pancreas, kidney, or large intestine.
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? 2:00 pm 3:00 pm 4:00 pm 6:00 pm
Correct response: 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.
Which is a symptom of severe thrombocytopenia? Petechiae Inflammation of the mouth Inflammation of the tongue Dyspnea
Correct response: 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.
A nurse is assisting a client into position prior to bone marrow aspiration. Which position will the nurse place the client prior to the procedure? Supine Prone Knee-chest Trendelenberg
Correct response: Prone Explanation: Prior to the bone marrow aspiration, the nurse should place the client in either the prone position or lateral position with one leg flexed. The aspiration usually is performed on the anterior iliac crest. It would not be appropriate for the nurse to place the client in supine, knee-chest, or Trendelenburg positions.
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 an allergic reaction to the blood. The client is experiencing vascular collapse. The client is having decrease in tissue perfusion from a shock state. The client is having a febrile nonhemolytic reaction.
Correct response: The client is having a febrile nonhemolytic reaction. Explanation: The signs and symptoms of a febrile nonhemolytic transfusion reaction are chills (minimal to severe) followed by fever (more than 1°C elevation). The fever typically begins within 2 hours after the transfusion is begun. Although the reaction is not life threatening, the fever, and particularly the chills and muscle stiffness, can be frightening to the client.
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? Notify the physician Administer aspirin (ASA) 325 mg po, as ordered Administer acetaminophen 500 mg po, as ordered Reposition the client to a high Fowler position and continue to monitor the pain
Correct response: Administer acetaminophen 500 mg po, as ordered Explanation: After a marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing. Most clients have no discomfort after a bone marrow biopsy, but the site of a biopsy may ache for 1 or 2 days. Warm tub baths and a mild analgesic agent (e.g., acetaminophen) may be useful. Aspirin-containing analgesic agents should be avoided it the immediate post-procedure period because they can aggravate or potentiate bleeding.
The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level? Bright red venous blood. Elevated temperature. Decreased oxygen level. Increased bruising.
Correct response: Decreased oxygen level. Explanation: Hemoglobin carries oxygen; a decreased hemoglobin level results in decreased oxygen. An elevated temperature is a sign of infection and can result from decreased white blood cells. Arterial blood is more oxygen saturated and brighter red in color than venous blood. Increased bruising results from a decreased platelet level, not decreased hemoglobin.
A nurse is completing a detailed health history and assessment in the electronic medical record (EMR) for a client with a disorder of the hematopoietic system. Which symptom is the most commonly reported in association with hematologic diseases? Extreme fatigue Severe headaches Dyspnea Blurred vision
Correct response: Extreme fatigue Explanation: When assessing a client with a disorder of the hematopoietic system, it is essential to assess for the most common symptom in hematologic diseases, which is extreme fatigue.
Which nursing intervention should be incorporated into the plan of care for a client with impaired liver function and a low albumin concentration? Implement neutropenic precautions Apply prolonged pressure to needle sites or other sources of external bleeding Monitor for edema at least once per shift Monitor temperature at least once per shift
Correct response: Monitor for edema at least once per shift Explanation: Albumin is particularly important for the maintenance of fluid balance within the vascular system. Capillary walls are impermeable to albumin, so its presence in the plasma creates an osmotic force that keeps fluid within the vascular space. Clients with impaired hepatic function may have low concentrations of albumin, with a resultant decrease in osmotic pressure and the development of edema.
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? Myelodysplastic syndrome Neutropenia Anemia Thrombocytopenia
Correct response: Anemia Explanation: Individuals with a history of alcohol consumption may have anemia due to nutritional deficiencies. Myelodysplastic syndrome, neutropenia, and thrombocytopenia are not common findings in clients who consume or abuse alcohol.
A client with chronic kidney disease has chronic anemia. What pharmacologic alternative to blood transfusion may be used for this client? GM-CSF Erythropoietin Eltrombopag Thrombopoietin
Correct response: Erythropoietin Explanation: Erythropoietin (epoetin alfa [Epogen, Procrit]) is an effective alternative treatment for clients with chronic anemia secondary to diminished levels of erythropoietin, as in chronic renal disease. This medication stimulates erythropoiesis.
Which type of lymphocyte is responsible for cellular immunity? B lymphocyte Plasma cell T lymphocyte Basophil
Correct response: 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.
The nurse is working at a blood donation clinic. What teaching should the nurse provide to the donor immediately after blood donation? Hold the involved arm below the heart. Remove the band-aid after 5 minutes. Sit up promptly after the needle is removed. Remain for observation after eating and drinking.
Correct response: Remain for observation after eating and drinking. Explanation: After blood donation, the donor receives food and fluids and is asked to remain for observation. After the needle is removed, donors are asked to hold the involved arm straight up, and firm pressure is applied with sterile gauze for 2 to 3 minutes. A firm bandage is then applied. The donor remains recumbent until he or she feels able to sit up, usually within a few minutes.
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.
Correct response: 5 Explanation: 1 mg/kg X 50 kg = 50 mg then divide by 10 mg/mL = 5 mL
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 Blood transfusion reaction Shock Splintering of bone fragments
Correct response: Hemorrhage Explanation: Hazards of either bone marrow aspiration or biopsy include bleeding and infection. The risk of bleeding is somewhat increased if the patient's platelet count is low or if the patient has been taking a medication (e.g., aspirin) that alters platelet function.
Place the clotting cascade in the correct order. Prothrombin Prothrombin activator Fibrin Thrombin Fibrinogen
Correct response: Prothrombin activator Prothrombin Thrombin Fibrinogen Fibrin Explanation: There is an intrinsic and extrinsic clotting pathway with various clotting factors unique to each. However, the common clotting cascade is the end result in both pathways. Prothrombin activator form prothrombin, which forms thrombin, then fibrinogen, and finally fibrin.
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 Extreme leukocytosis Sickle cell anemia Renal transplantation
Correct response: Essential thrombocythemia Explanation: Platelet pheresis is used to remove platelets from the blood in patients with extreme thrombocytosis or essential thrombocythemia (temporary measure)or in a single-donor platelet transfusion.
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 folate deficiency." "The condition causes abnormally small red blood cells." "The condition is likely caused by a vitamin B12 deficiency." "The condition causes abnormally rigid red blood cells."
Correct response: "The condition is likely caused by a vitamin B12 deficiency." Explanation: 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 the absorption of vitamin B12 may be diminished. Megaloblastic anemia may be caused by a folate deficiency; however, the client's history of gastrectomy indicates the likely cause is a vitamin B12 deficiency. Megaloblastic anemia causes large erythrocytes (RBCs), not small or rigid.
Which term refers to a form of white blood cell involved in immune response? Granulocyte Lymphocyte Spherocyte Thrombocyte
Correct 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.
Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets? Myeloid stem cell Lymphoid stem cell Monocyte Neutrophil
Correct response: 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.
Which blood cell type is matched correctly with its function? T lymphocyte: Humoral immunity Plasma cell: Cell-mediated immunity Leukocyte: Fights infection B lymphocyte: Secretes immunoglobulin
Correct response: Leukocyte: Fights infection Explanation: Various blood cell types have unique, major functions. Leukocytes fight infection, T lymphocytes are integral in cell-mediated immunity, plasma cells secrete immunoglobulin, and B lymphocytes are integral in humoral immunity.
A client wants to donate blood before his or her abdominal surgery next week. What should be the nurse's first action? Provide the client with a list of the nearest donation centers. Explain the time frame needed for autologous donation. Remind the client to take supplemental iron before donation. Tell the client that 2 units of blood will be needed.
Correct response: 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.
The nurse should provide further teaching about post bone-marrow biopsy procedures when the client makes which statement? "I'll ask someone to drive me home when I awake from general anesthesia." "I should not take aspirin-containing products for pain relief." "I may feel some aching in my hip for 1-2 days." "I will keep the sterile dressing on until my doctor tells me it's okay to remove it."
Correct response: "I'll ask someone to drive me home when I awake from general anesthesia." Explanation: A bone marrow biopsy is usually performed with local anesthesia, not general. Aspirin can increased the risk of bleeding and should be avoided post procedure. The client should expect to feel some aching in the hip area for 1-2 days. A sterile dressing is applied upon completion of the procedure and should remain in place until the healthcare provider tells the client it is safe to remove.
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? the wound with half-inch sterile gauze Administer a topical analgesic to control pain at the site Apply pressure over the site for 5-7 minutes Elevate the head of the bed to 45 degrees
Correct response: Apply pressure over the site for 5-7 minutes Explanation: Hazards of either bone marrow aspiration or biopsy include bleeding and infection. The risk of bleeding is somewhat increased if the client's platelet count is low or if the client has been taking a medication (e.g., aspirin) that alters platelet function. After the marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing.
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 Lithotomy position Supine with head of the bed elevated 30 degrees Jackknife position
Correct response: 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.
Place the following procedural steps in order for transfusing a unit of packed red blood cells (PRBCs). 1Start an intravenous line. 2Obtain the unit of PRBCs from the blood bank. 3Double check the labels with another nurse to ensure correct ABO group and Rh type. 4Initiate the blood transfusion within 30 minutes of receipt. 5Monitor closely for signs of a transfusion reaction.
Correct response: Start an intravenous line. Obtain the unit of PRBCs from the blood bank. Double check the labels with another nurse to ensure correct ABO group and Rh type. Initiate the blood transfusion within 30 minutes of receipt. Monitor closely for signs of a transfusion reaction. Explanation: The nurse should first start an intravenous line, obtain the PRBCs, double check labels, start the transfusion, and then monitor for a reaction.
A nursing instructor in a BSN program is preparing for a lecture on disorders of the hematopoietic system. Included in the lecture are conditions caused by reduced levels or absence of blood-clotting proteins. Which of the following is the instructor most likely referring to? Coagulopathy Aplastic anemia Pancytopenia Sickle cell disease
Correct response: Coagulopathy Explanation: The term coagulopathy refers to conditions in which a component that is necessary to control bleeding is missing or inadequate.
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 Calcium Hemoglobin Potassium
Correct response: Iron Explanation: Iron overload is a complication unique to people who have had long-term PRBC transfusion. Over time, the excess iron deposits in body tissues can cause organ damage, particularly in the liver, heart, testes, and pancreas.
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 Lean meats Nuts and seeds Animal fats Organic foods
Correct response: Leafy green vegetables Lean meats Nuts and seeds Explanation: A healthy diet that includes lean meats, nuts, seeds and green vegetables can promote red cell production. Animal fats are not known to promote red cell production. Organic foods are not necessarily more likely to promote red cell synthesis.
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? Assess the client's vital signs. Stop the infusion. Call the health care provider. Slow the infusion.
Correct response: Stop the infusion. Explanation: A client with impaired renal function is at increased risk for transfusion-associated circulatory overload (TACO). Signs of circulatory overload include dyspnea, orthopnea, tachycardia, an increase in blood pressure, and sudden anxiety. If the symptoms are mild, the nurse may be able to slow the infusion and administer diuretics; however, sudden shortness of breath should clue the nurse to immediately stop the infusion and sit the client upright with feet dangling. Next, the nurse will notify the health care provider after normal saline is infused into the site. Only after stopping the infusion will the nurse obtain the client's vital signs.
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 stimulate erythropoietin, stimulating the marrow to produce more red blood cells. The bone marrow is stimulated by low oxygen levels in the blood and stimulates erythropoietin, maturing the red blood cells. The brain senses low oxygen levels in the blood and stimulates hemoglobin, which binds to more red blood cells. The kidneys sense low oxygen levels in the blood and stimulate hemoglobin, stimulating the marrow to produce more red blood cells.
Correct response: The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells. Explanation: If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (as with anemia), erythropoietin levels increase, stimulating the marrow to produce more erythrocytes (red blood cells).
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 agree that you should be concerned with the safety of the blood, but it is important that you have this transfusion." "The blood is carefully screened, so there is no possibility of you contracting any illness or disease from the blood." "I understand your concern. The blood is carefully screened but is not completely risk free." "You will have to decide if refusing the blood transfusion is worth the risk to your health."
Correct response: "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 spinach salad with lunch and dinner." "I will eat a meat source such as chicken or pork with each meal." "I will increase my daily intake of orange vegetables such as sweet potatoes and carrots." "I will eat more dairy products such as milk, yogurt, and ice cream every day."
Correct response: "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. The other choices do not include meats. Dairy products contain large amounts of Calcium and vitamin D. Orange vegetables contain large amounts of vitamin A.
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." "I should expect blood withdrawal to take about 15 minutes." "Donated blood is tested for blood type and infections." "I could donate my own blood in case I need a transfusion."
Correct response: "My family will donate blood, because it's safer." Explanation: Directed donations from friends and family members are not any safer than those provided by random donors. Withdrawal of 450 mL of blood usually takes about 15 minutes. Specimens from donated blood are tested to detect infections and to identify the specific blood type. Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high.
Which client is not a candidate for blood donation according to the American Heart Association? 86 year old male with blood pressure 110/70 mmHg 50 year old female with pulse 95 beats/minute 26 year old female with hemoglobin 11.0 g/dL 18 year old male weighing 52 kg.
Correct response: 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 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. Globulin. Fibrinogen. Prothrombin.
Correct response: Albumin. Explanation: Albumin, only produced in the liver, is essential for maintaining oncotic pressure in the vascular system. A decrease in oncotic pressure due to low albumin causes fluid to leak into the peritoneal cavity.
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? White blood cell filter Hepatitis B immunization Red blood cell phenotyping Chelation therapy
Correct response: 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? Isometric exercise programs are inclusive of all muscle groups and have an aerobic effect to increase the heart rate. Isometric exercise decreases the workload of the heart and restores oxygenated blood flow. This type of exercise increases arterial circulation as it returns to the heart. Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.
Correct response: 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 Respiratory rate of 10 breaths/minute Oral temperature of 97°F Pain and tenderness in calf area
Correct response: 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.
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 Decreased total iron-binding capacity Increased mean corpuscular volume Increased reticulocyte count
Correct response: 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 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? Add the morphine to the blood to be slowly administered. Inject the morphine into a distal port on the blood tubing. Administer the morphine into the closest tubing port to the client for fast delivery. Disconnect the blood tubing, flush with normal saline, and administer morphine.
Correct response: 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.
During a blood transfusion with packed red blood cells (RBCs), a client reports chills, low back pain, and nausea. What priority action should the nurse take? Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing Discontinue the infusion immediately and notify the physician Slow the infusion rate and continue to monitor the client every 15 minutes Observe for additional symptoms and notify the physician
Correct response: Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing Explanation: The following steps are taken to determine the type and severity of the reaction: Stop the transfusion. Maintain the IV line with normal saline solution through new IV tubing, administered at a slow rate. Assess the client carefully. Notify the physician. Continue to monitor the client's vital signs and respiratory, cardiovascular, and renal status. Notify the blood bank that a suspected transfusion reaction has occurred. Send the blood container and tubing to the blood bank for repeat typing and culture.
The charge nurse should intervene when observing a new nurse perform which action after a client has suffered a possible hemolytic blood transfusion reaction? Notifying the blood bank of the reaction. Disposing of the blood container and tubing in biohazard waste. Informing the client to leave a urine sample after the client's next void. Documenting the reaction in the client's medical record.
Correct response: 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 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? Place the client in a recumbent position with legs elevated. Remove the intravenous line. Ensure there is an oxygen delivery device at the bedside. Administer prescribed PRN anti-anxiety agent.
Correct response: 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.
Splenic sequestration is diagnosed in a client admitted with splenomegaly. What is the priority of care for this client? Infection Hypovolemia Hyperthermia Hypertension
Correct response: Hypovolemia Explanation: If the spleen is enlarged, a greater proportion of red cells and platelets can be sequestered. With less red blood cells in circulation, the client can become hypovolemic resulting in shock. Decreased white blood cells in circulation, not red blood cells, increases the chance of infection. Decreased circulatory volume results in hypotension, not hypertension. Hyperthermia is not a result of decreased red blood cells in circulation.
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 Oxygen therapy Therapeutic phlebotomy Anticoagulation therapy
Correct response: 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.
A client develops a hemolytic reaction to a blood transfusion. What actions should the nurse take after this occurs? Select all that apply. Administer diphenhydramine Begin iron chelation therapy Obtain appropriate blood specimens Collect a urine sample to detect hemoglobin Document the reaction according to policy
Correct response: Obtain appropriate blood specimens Collect a urine sample to detect hemoglobin Document the reaction according to policy Explanation: If a hemolytic transfusion reaction or bacterial infection is suspected, the nurse does the following: obtains appropriate blood specimens from the client; collects a urine sample as soon as possible to detect hemoglobin in the urine; and documents the reaction according to the institution's policy.
Which is the major function of neutrophils? Rejection of foreign tissue Phagocytosis Destruction of tumor cells Production of immunoglobulins
Correct response: Phagocytosis Explanation: Once a neutrophil is released from the marrow into the circulation, it stays there for only about 6 hours before it migrates into the body tissues to perform its function of phagocytosis (ingestion and digestion of bacteria and particles). Neutrophils die there within 1 to 2 days. T lymphocytes are responsible for rejection of foreign tissue and destruction of tumor cells. Plasma cells produce antibodies called immunoglobulins.
Under normal conditions, the adult bone marrow produces approximately 70 billion neutrophils. What is the major function of neutrophils? Phagocytosis Rejection of foreign tissue Destruction of tumor cells Production of antibodies called immunoglobulin (Ig)
Correct response: 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.
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-negative child Rh-positive mother; Rh-negative child Rh-negative mother; Rh-positive child Rh-positive mother; Rh-positive child
Correct response: Rh-negative mother; Rh-positive child Explanation: A mother who is Rh negative and gives birth to an Rh positive child is at greatest risk for a febrile nonhemolytic reaction because exposure to an Rh-positive fetus raises antibody levels in the Rh negative mother. An Rh-negative mother can carry an Rh-negative child without being at greatest risk for a febrile nonhemolytic reaction; however, these mothers are often treated prophylactically. An Rh-positive mother may carry either an Rh-positive or Rh-negative child without increased risk.
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? Flush the blood tubing with normal saline. Discontinue the intravenous line. Stop the infusion. Notify the primary health care provider.
Correct response: Stop the infusion. Explanation: The client's symptoms are consistent with a possible blood transfusion reaction. The infusion should be stopped immediately, then the primary health care provider should be notified. The intravenous line should not be discontinued in case the client needs any emergency intravenous medications. Flushing the blood tubing with normal saline would allow the blood in the tubing to be infused; the IV line should be maintained with normal saline through brand new tubing.
Place the following steps in order when determining the type and severity of a transfusion reaction. Use all options. Notify the blood bank. Stop the transfusion. Notify the health care provider. Send the tubing and container to the blood bank. Assess the client.
Correct response: Stop the transfusion. Assess the client. Notify the health care provider. Notify the blood bank. Send the tubing and container to the blood bank. Explanation: It is important for the nurse to take the proper steps when determining the type and severity of a transfusion reaction. The priority action is to stop the infusion and then assess the client. Next, the health care provider will be notified, followed by the blood bank. Finally, the nurse should send the tubing and container to the blood bank for analysis.
A nursing instructor is reviewing the role and function of stem cells in the bone marrow with a group of nursing students. After providing the explanation, the instructor asks the students to use their knowledge of anatomy and physiology to determine an alternate way in which adults with diseases that destroy marrow can resume production of blood cells. Which explanation by the students is correct? Fat found in yellow bone marrow can be replaced by active marrow when more blood cell production is required. The remaining stem cells have the ability to continue with the process of self-replication, creating an endless supply. The liver and spleen can resume production of blood cells through extramedullary haematopoiesis. The three cell types—erythrocytes, leukocytes, and platelets—can resume production of stem cells.
Correct response: The liver and spleen can resume production of blood cells through extramedullary haematopoiesis. Explanation: In adults with disease that destroy marrow or cause fibrosis or scarring, the liver and spleen can also resume production of blood cells through a process known as extramedullary hematopoiesis.
When teaching about the advantages of autologous blood transfusion to a client, the nurse should include which information? Select all that apply. The primary advantage is prevention of viral infections. It is safer for clients with a history of transfusion reactions. It resolves anemia for clients with a hemoglobin less than 11g/dL. Blood can be transfused to family members and close relatives. If not needed immediately, the blood can be frozen for future use.
Correct response: The primary advantage is prevention of viral infections. It is safer for clients with a history of transfusion reactions. If not needed immediately, the blood can be frozen for future use. Explanation: The primary advantage of autologous transfusions is the prevention of viral infections from another person's blood. Other advantages include safe transfusion for client with a history of transfusion reactions; and if the blood is not required immediately, it can be frozen until the donor needs it. It is the policy of the American Red Cross that autologous blood is transfused only to the donor. Hemoglobin level less than 11g/dL is a contraindication to autologous blood donation.
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. Elevate the client's head of the bed. Where a mask when entering the client's room. Apply supplemental oxygen to maintain the client's oxygenation.
Correct response: Use an electric razor when assisting client with shaving. Explanation: Petechiae are associated with severe thrombocytopenia, placing the client at risk for bleeding. The nurse should use an electric razor when assisting the client with shaving. Elevating the head of the bed and applying supplemental oxygen would be appropriate for a client with decreased oxygenation. Wearing a mask when entering the client's room would be appropriate for a client with neutropenia, not thrombocytopenia.
The client is to receive a unit of packed red blood cells. What is the nurse's first action? Check the label on the unit of blood with another registered nurse. Ensure that the intravenous site has a 20-gauge or larger needle. Observe for gas bubbles in the unit of packed red blood cells. Verify that the client has signed a written consent form.
Correct response: Verify that the client has signed a written consent form. Explanation: All the options are interventions the nurse will do to ensure the blood transfusion is safe. The question asks about the first action of the nurse. The first action would be verifying that the client has signed a written consent form. Then, the nurse would ensure the intravenous site has a 20-gauge or larger needle. The nurse would proceed to obtain the unit of blood, check the blood with another registered nurse, and observe for gas bubbles in the unit of blood.
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 Administer the blood as soon as it arrives Premedicate the client with acetaminophen Assess the client 30 minutes after the start of the initial transfusion
Correct response: Verify the client's identity according to hospital policy Explanation: Acute hemolytic transfusion reactions are preventable. Improper identification is responsible for the majority of hemolytic transfusion reactions. Meticulous attention to detail in labeling blood samples and blood components and accurately identifying the recipient cannot be overemphasized. It is the nurse's responsibility to ensure that the correct blood component is transfused to the correct client. The nurse must assess the client during the initial start of the transfusion and frequently, if the nurses delays the assessment time for 30 minutes the client may have begun to experience acute hemoloytic transfusion reaction, this puts the client's safety at risk.
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. may be developing anemia. has leukopenia. has thrombocytopenia.
Correct response: 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.
