Chapter 30, 31, 16: Adaptive Quizzes
A patient diagnosed with factor VIII deficiency has joint bleeding. Which nursing interventions would be beneficial for the patient? Select all that apply.
-Pack the joint in ice. -Provide analgesics such as acetaminophen. -Encourage the patient to do range-of-motion exercises when bleeding is stopped. Factor VIII deficiency leads to hemophilia, which is a severe bleeding disorder. When joint bleeding occurs, the joint should be packed in ice to reduce bleeding. Analgesics such as acetaminophen should be provided to reduce pain. When bleeding is stopped, the patient should be encouraged to perform range-of-motion exercises to increase mobilization. Aspirin should be avoided, because it may increase bleeding. Weight bearing activity should be performed when the swelling has decreased and muscle strength has returned.
After reviewing the diagnostic reports of a patient, the nurse anticipates that the patient has acute lymphocytic leukemia. Which findings in the patient's diagnostic reports support the nurse's anticipation? Select all that apply.
-Presence of lymphocytes in cerebrospinal fluid -Presence of hypercellular bone marrow with lymphoblasts -Acute lymphocytic leukemia is characterized by lymphoblasts in cerebrospinal fluid and hypercellular bone marrow with lymphoblasts. Acute myelogenous leukemia is characterized by an increase in the number of myeloblasts. Chronic lymphocytic leukemia is characterized by the accumulation of small, mature-appearing lymphocytes. Chronic myelogenous leukemia occurs when there is an excessive development of mature neoplastic granulocytes in the bone marrow.
To prepare for a transfusion of packed red blood cells, the nurse selects which intravenous 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 the patient receives blood that is left in the tubing when the bag is empty. Lactated Ringer's, 5% dextrose in water, and 3% normal saline are not compatible with blood products.
An 82-year-old patient has a prescription to receive a transfusion of two units of packed red blood cells. The nurse would ask which health team member to assist in checking the unit 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 and UAP are not licensed to perform this duty.
A nursing student is caring for a patient with thrombocytopenia under the supervision of a registered nurse. Which action of the student nurse indicates an understanding of proper care for a patient with thrombocytopenia?
Applying ice on the injection site -Intramuscular injection should be avoided in a patient with thrombocytopenia because hematomas may develop on the injected site due to improper clotting of blood. Ice packs should be applied after injection to provide comfort. Applying direct pressure on the injected site will reduce the risk of hematoma, so direct pressure should not be avoided. Using a large-gauge needle for subcutaneous injection will cause bleeding.
After performing the bone marrow aspiration, the nurse finds that the patient has bleeding at the site of aspiration. Which is the best nursing intervention in this situation?
Asking the patient to sleep on the site for 30 minutes -The nurse would ask the patient to sleep on the site of aspiration. This action reduces bleeding due to the application of pressure on the site. Warfarin is an anticoagulant, which increases bleeding. Therefore, the patient would have excess bleeding after taking warfarin. Ibuprofen is a nonsteroidal antiinflammatory drug used to help reduce pain. However, it is not effective in reducing bleeding. A soft bed will not apply as much pressure to the site. Hence, the nurse asks the patient to roll a towel and apply pressure to the site if sleeping on soft bed.
The diagnostic findings of a patient indicate accumulation of small, mature-appearing lymphocytes in the bone marrow. Which condition is most likely to be present in this patient?
Chronic lymphocytic leukemia -Chronic lymphocytic leukemia is associated with the accumulation of small, mature-appearing lymphocytes in the bone marrow. Myelogenous leukemia is characterized by the proliferation of myeloblasts. Acute lymphocytic leukemia is characterized by the uncontrolled proliferation of immature small lymphocytes in the bone marrow. Chronic myelogenous leukemia is characterized by the proliferation of mature neoplastic granulocytes in the bone marrow.
While assessing the skin of a patient with anemia, the nurse would look for which manifestations?
Color pale or with a cyanotic tinge -In patients with red blood cell (RBC) disorders the skin may be pale or pasty, or it may have a cyanotic tinge in severe anemia. Yellowing of the skin, or jaundice, is caused by an accumulation of bile pigment caused by rapid or excessive hemolysis or liver damage. Flushed skin in the face and neck areas may indicate an increase in hemoglobin (polycythemia) or congestion of the capillaries. Erythrocytosis often produces small vessel occlusions, causing a purple, mottled appearance of the face, nose, fingers, or toes.
The diagnostic studies of a leukemia patient indicate normal bone marrow and peripheral blood and the physical examination does not show any evidence of disease. Which term is used to refer to this patient's condition?
Complete remission -In complete remission, the bone marrow and the peripheral blood appear normal. The patient does not show any evidence of disease upon physical examination. Partial remission is a condition characterized by: a lack of disease symptoms, a normal peripheral blood smear, and evidence of disease in the bone marrow. Molecular remission is the condition in which all molecular studies are negative for residual leukemia. Minimal residual disease refers to the tumor cells that cannot be detected by morphologic examination, but can be detected by molecular testing.
Which side effect does the nurse observe in a patient who is on ferrous gluconate?
Constipation -Iron supplements such as ferrous gluconate reduce peristalsis and result in constipation. Ferrous gluconate does not reduce blood pressure 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.
When assessing laboratory values of a patient admitted with septicemia, what should the nurse expect to find?
Increased bands in the white blood cell (WBC) differential (shift to the left) -When infections are severe, such as in septicemia, more granulocytes are released from the bone marrow as a compensatory mechanism. To meet the increased demand, many young, immature polymorphonuclear neutrophils (bands) are released into circulation. WBCs usually are reported in order of maturity (initially with the less mature forms on the left side of a written report). Hence, the term "shift to the left" is used to denote an increase in the number of bands. Thrombocytosis occurs with inflammation and some malignant disorders. A decreased number of red blood cells indicates anemia. A decreased ESR is not indicative of septicemia.
A patient suspected for malignancy is scheduled for a PET scan to highlight areas with increased metabolism. What is the appropriate nursing intervention in this situation?
Instructing the patient not to have anything by mouth except water and medications at least four hours before the test -Positron emission tomography (PET) is a radiologic study and a valuable diagnostic tool that detects malignancy because it highlights areas with increased metabolism. The nursing intervention for this patient would be to instruct him or her to avoid anything by mouth except for water and medications for at least four hours before the test. Application of pressure dressing is useful for the patient after a bone marrow biopsy, to reduce bleeding at the site. Administering analgesics before the procedure is beneficial in a bone marrow biopsy to enhance the patient's comfort and cooperation. The nurse should instruct the patient undergoing a bone scan to drink four to five glasses of water and void before the test.
A nurse is assessing a patient with chronic kidney disease. The nurse finds that the patient has pallor, and the blood reports are suggestive of anemia. What could be the most likely cause of anemia?
Decreased erythropoietin production rationale: Erythropoietin is a hormone secreted by the kidneys that stimulates the bone marrow cells to produce red blood cells (RBCs). Chronic kidney disease causes a reduction in erythropoietin production, which ultimately leads to a decreased production of RBCs. This results in anemia. Excessive blood loss results in anemia, but is not a likely cause in this patient. A decreased iron intake causes anemia, but is less likely in this patient. Hypothyroidism can indirectly lead to anemia, but it is not a cause in this patient, because the patient does not suffer from thyroid abnormality. The cause of anemia in this patient is related to the kidney disease.
Which medication is beneficial in a patient with thalassemia major receiving a blood transfusion who is showing signs of hemochromatosis?
Deferoxamine -A patient with thalassemia major requires frequent blood transfusions and is at risk of iron toxicity. Deferoxamine chelates with the iron and reduces iron overload or hemochromatosis. Methotrexate is an anticancer drug, and it does not reduce iron overload. Iron supplements such as ferrous gluconate and iron dextran complex should not be administered to the patient because they further increase the risk of iron overload.
The nurse is reviewing the objective data from a patient with suspected allergies. Which assessment finding does the nurse know indicates allergies?
Eosinophil result -Eosinophils are granulocytes that phagocytize antigen-antibody complexes formed during an allergic response. The normal eosinophil count is 2% to 4% of all white blood cells (WBCs). The dry cough, lymphocyte result, and acetaminophen use do not indicate allergies.
Which condition when inherited by the offspring may cause thrombocytopenia?
Fanconi syndrome -Fanconi syndrome is associated with low levels of blood platelets, and red and white blood cells in the patient. Therefore, inheritance of Fanconi syndrome can cause thrombocytopenia in the offspring. Myelofibrosis, splenomegaly, and myelodysplastic syndrome are acquired types of thrombocytopenia but they are not inherited genetically.
Which features differentiate lymphoma from leukemia?
Fewer circulating abnormal cells -A patient with lymphoma is likely to have fewer circulating abnormal cells compared to a patient with leukemia. Peripheral lymphocytosis with bone marrow involvement, which is commonly associated with leukemia, may also be present in about 20 percent of adults with some types of non-Hodgkin's lymphoma (NHL). Therefore, this feature does not differentiate lymphoma from leukemia. A patient with lymphoma would be more likely to have extensive rather than minimal nodal involvement. Both leukemia and lymphoma involve proliferation of lymphocytes or their precursors.
The surgical patient has a new prescription to be transfused with two units of packed red blood cells (PRBCs). The nurse should take which action to ensure patient safety?
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. 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.
Which statement is true regarding the Philadelphia chromosome?
It interferes with normal cell cycle events. -The protein that is encoded by the newly created BCR-ABL gene on the Philadelphia chromosome interferes with normal cell cycle events such as the regulation of cell proliferation. The Philadelphia chromosome is not specific to diagnose CML, because it is also found in ALL and occasionally in AML. The Philadelphia chromosome is present in 20 to 25 percent of patients with ALL. It is present in 90 to 95 percent of patients with CML and is a diagnostic hallmark of CML.
A nurse is assessing a patient with nonhemolytic anemia. What integumentary finding is indicative of anemia?
Pallor -A common integumentary change observed in anemia is pallor. Pruritus is seen in conditions associated with an increase in serum bile salts. Jaundice is seen in hemolytic anemia due to increased serum bilirubin. Hyperpigmentation is usually not associated with anemia.
A patient with leukemia, who is on induction therapy, shows absence of any symptoms of the disease. The peripheral blood smear of the patient is normal, but the bone marrow shows evidence of the disease. Which term is used to refer to the patient's condition?
Partial remission -Partial remission is a condition in which there is a lack of symptoms of the disease and a normal peripheral blood smear, but evidence of the disease in the bone marrow. Complete remission refers to the condition in which the bone marrow and the peripheral blood appear normal. Molecular remission is the condition in which all molecular studies are negative for residual leukemia. Minimal residual disease refers to the tumor cells that cannot be detected by morphologic examination, but can be detected by molecular testing.
Which condition is the most common cause for hematemesis?
Peptic ulcer disease -Hematemesis is bright red, brown, or black vomitus, associated with an underlying disease like peptic ulcer disease. Thalassemia is a hereditary autosomal disorder characterized by the abnormal growth of red blood cells or hemoglobin. Sickle cell anemia is a hereditary disorder, which manifests as a distorted shape of hemoglobin. Pernicious anemia is a deficiency in the production of red blood cells due to lack of vitamin B12.
The nurse provided patient teaching regarding daily activities of a patient who has thrombocytopenia. Which activity of the patient indicates an understanding of the teaching?
Shaving using an electric razor -A patient with thrombocytopenia has a decreased number of platelets and, therefore, prolonged bleeding will be observed even for minor injuries. Shaving using an electric razor blade decreases the risk of cuts and wounds resulting in decreased bleeding. Therefore, this activity of the patient indicates understanding of the nurse's teaching. Walking with flip flops can cause the patient to trip, causing the risk for cuts or wounds and increased bleeding. Flossing using a thick tape floss is not safe and can cause an increased risk for bleeding. Brushing using a stiff-bristle toothbrush causes injury to the gums and is not safe; therefore the nurse needs to perform more patient teaching.
The nurse is assessing a female patient who has hemophilia. What would the nurse infer about the patient's family?
The father has hemophilia and the mother is a carrier of hemophilia. -Hemophilia is an X-linked recessive genetic disorder caused by a defective or deficient coagulation factor. For a female to be hemophilic, both the X chromosomes should carry hemophilia, because it is a recessive disorder. The daughter can have hemophilia if her father has hemophilia and the mother is a carrier for hemophilia. If the father or mother is unaffected by hemophilia the daughter will not have hemophilia, because it is an X-linked recessive disorder.
While assessing a patient, the nurse finds a smooth and shiny tongue surface. What does the nurse infer from these findings?
The patient has pernicious anemia. -A smooth, shiny tongue surface can be observed in patients with pernicious anemia. A pallor of the gingival and mucosal membrane is observed due to low hemoglobin level. Patients with neutropenia may have gingival and mucosal ulceration, swelling, or bleeding. Patients with polycythemia may have decreased visual acuity and transient episodic redness of the skin. A patient with elevated estrogen levels may have spider nevus, a form of telangiectasia.
Before hanging a unit of packed red blood cells, the nurse would arrange for another nurse to monitor his or her assignment for how many minutes while the nurse administers the transfusion?
15 mins -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. f
When is consolidation therapy indicated in patients with leukemia?
After remission is achieved -Consolidation therapy is started after remission is achieved in patients with leukemia. Maintenance therapy is initiated after postinduction therapy, which consists of both intensification and consolidation therapy. Intensification therapy should be given immediately after induction therapy. Induction therapy is given initially when the treatment is indicated in the patient.
Which patient is most likely to experience anemia related to an increased destruction of red blood cells?
A 23-year-old African American man who has a diagnosis of sickle cell disease -A result of a sickling episode in sickle cell anemia involves increased hemolysis of the sickled cells. Thalassemias and folic acid deficiencies cause a decrease in erythropoiesis, whereas the anemia related to menstruation is a direct result of blood loss.
A nurse is assessing four patients. Which patient is most likely to have thrombotic thrombocytopenic purpura (TTP)?
A 35-year old female adult -Thrombotic thrombocytopenic purpura (TTP) is seen primarily in adults between 20 and 50 years of age, with a slight female predominance. Therefore, a 35-year old female adult is more likely to have TTP. A 12-year-old male child, a 30-year old male adult, and a 10-year-old female child are less likely to have TTP than a 35-year old female adult is.
The nurse is reviewing the hematologic test results of a patient with leukemia. Which test result places the patient at high risk for developing infection?The nurse is reviewing the hematologic test results of a patient with leukemia. Which test result places the patient at high risk for developing infection?
Absolute neutrophil count (ANC) 500 cells/μL -ANC neutropenia indicates an increased risk of developing infection. Platelet count, total RBC count, and MCHC are in the normal range.
Which leukemia is most commonly seen in children?
Acute lymphocytic leukemia -Acute lymphocytic leukemia is most commonly seen in children. Acute myelogenous leukemia, chronic lymphocytic leukemia, and chronic myelogenous leukemia are commonly seen in older adults.
A patient is scheduled for a Schilling test. The nurse explains that the purpose of the test is to measure:
B12 absorption -The Schilling test measures B12 absorption. It is usually prescribed as the definitive test for pernicious anemia when other signs of the disease are present. A Schilling test does not measure the size of the spleen, gastric secretion levels, or thrombocytopenia severity.
A patient with neutropenia is placed in protective (reverse) isolation. The nurse explains to visitors that the primary purpose of the isolation is to help prevent the spread of organisms:
By preventing spread to the patient from sources outside the patient's environment -The primary purpose of protective, or reverse, isolation is to reduce transmission of organisms to the patient from sources outside the patient's environment. The use of special techniques to destroy discharge or handle the patient's linen and personal items and preventing the spread from the patient to others are not the purpose of protective isolation.
Which deficiency causes hemophilia B in a patient?
Christmas factor deficiency -Christmas factor, or factor IX, is a clotting protein and its deficiency causes hemophilia B; this leads to prolonged or spontaneous bleeding. Iron deficiency causes anemia. Anti-hemophilic factor, or factor VIII deficiency, causes hemophilia A. Von Willebrand coagulation protein deficiency causes von Willebrand disease.
The nurse cares for a patient with iron-deficiency anemia. Which nursing diagnostic statement associated with the condition is the highest priority?
Impaired gas exchange -Iron is necessary for hemoglobin synthesis. Hemoglobin is responsible for oxygen transport in the body. With iron-deficiency anemia a subnormal hemoglobin level cannot carry enough oxygen to the tissues. This results in impaired tissue oxygenation caused by impaired gas exchange. Deficient fluid volume and decreased cardiac output are not directly associated with iron-deficiency anemia. An impaired breathing pattern may develop as a result of impaired gas exchange.
The physical assessment of a patient reveals ecchymoses and subcutaneous hematomas. The patient's medical record indicates hemophilia A. The patient is prescribed desmopressin acetate. What would be the expected therapeutic outcome in this patient?
Increase in factor VIII -Ecchymoses and subcutaneous hematomas are the clinical manifestations of bleeding in a patient with hemophilia A. Desmopressin acetate is used to stimulate an increase in factor VIII in patients with hemophilia. An increase in platelet count is a therapeutic outcome related to corticosteroids and immunosuppressants, which are used in the treatment of thrombocytopenia. An increase in hemoglobin is seen in the patients who are receiving erythropoietin therapy for anemia. Granulocyte colony-stimulating factors such as filgrastim and pegfilgrastim are used in the treatment of neutropenia. These drugs stimulate the production of neutrophils, thereby increasing the neutrophil count.
Which clinical manifestation in a patient suspected of having leukemia may indicate acute lymphocytic leukemia?
Leukemic meningitis -Central nervous system manifestations, such as leukemic meningitis, are most commonly observed in patients with acute lymphocytic leukemia (ALL). Gingival hyperplasia in patients is associated with acute myelogenous leukemia. Lymphadenopathy is also observed in patients with chronic lymphocytic leukemia. Hepatosplenomegaly is also common in patients with acute myelonogenous leukemia and chronic lymphocytic leukemia.
A patient has a hemoglobin level of 11 g/dL. The nurse determines that the patient has what level of severity of anemia?
Mild anemia -In mild anemia, hemoglobin is in the range of 10-12 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 severe anemia, it is less than 6 g/dL. 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).
Which diagnostic finding is a hallmark of chronic myelogenous leukemia?
Presence of Philadelphia chromosome -The Philadelphia chromosome is present in 90 to 95 percent of patients with chronic myelogenous leukemia (CML) and is referred to as a diagnostic hallmark of chronic myelogenous leukemia. Thrombocytopenia is not specific for CML. It is common in any type of leukemia. Acute lymphocytic leukemia (ALL) is usually associated with the presence of lymphoblasts in the cerebrospinal fluid. ALL and chronic lymphocytic leukemia are associated with hypercellular bone marrow with lymphoblasts.
A patient who is on heparin therapy manifests signs of heparin overdose. Which medication would be beneficial to the patient in this situation?
Protamine sulfate -Protamine sulfate reverses the anticoagulant effects of circulating heparin during severe clotting. Lepirudin is given to maintain anticoagulation. Rituximab is given to reduce the immune recognition of platelets. Prednisone is used to suppress the phagocytic response of splenic macrophages.
An older patient relates that he or she has increased fatigue and a headache. The nurse identifies pale skin and glossitis on assessment. In response to these findings, which teaching will be helpful to the patient if he or she has microcytic, hypochromic anemia?
Take the iron with orange juice one hour before meals. -With microcytic, hypochromic anemia, there may be an iron, B6, or copper deficiency, thalassemia, or lead poisoning. The iron prescribed should be taken with orange juice one hour before meals as it is absorbed best in an acid environment. Megaloblastic anemias occur with cobalamin (vitamin B12) and folic acid deficiencies. Vitamin B12 may help red blood cell (RBC) maturation if the patient has the intrinsic factor in the stomach. Green leafy vegetables provide folic acid for RBC maturation. Antiseizure drugs may contribute to aplastic anemia or folic acid deficiency, but the patient should not stop taking the medications. Changes in medications will be prescribed by the health care provider.
The nurse is performing a health history and physical examination on a newly admitted patient. Significant information obtained from the physical examination that relates to the hematologic system includes
The presence of petechiae -Note any petechiae or ecchymotic areas on the skin and, if present, document the frequency, size, and cause. The location of petechiae can indicate an accumulation of blood in the skin or mucous membranes. Small vessels leak under pressure, and the platelet numbers are insufficient to stop the bleeding. Petechiae are more likely to occur where clothing constricts the circulation. Bladder surgery, multiple pregnancies, and early menopause do not relate to the hematologic system.
A nurse is caring for a patient that has a platelet count below 100,000/μL. The nurse should monitor the patient for what complications?
Thrombocytopenia -Thrombocytopenia is a condition in which the platelet counts falls below 100,000/μL. Normal platelet counts are between 150,000 and 400,000/μL. Leukemia is a type of cancer of the blood or bone marrow characterized by an abnormal increase of immature white blood cells. Leukopenia is a condition in which the white blood cell count is less than 4000/μL. Neutropenia is a condition in which the absolute neutrophil count (ANC) is less than 1000 cells/μL.
A nurse is reviewing the laboratory reports of a patient. Which parameter would require further investigation?
Total WBC count of 3000/µL -A normal WBC count is 4,000-11,000/µL. A count less than 4000/µL indicates bone marrow depression and severe or chronic illness, and needs further investigation. A hemoglobin level of 13.0 g/dL is a normal value. A hematocrit of 38% is within the normal range. A normal platelet count ranges from 150,000 to 400,000/µL, and a platelet count of 200,000/µL is within normal limits.
A patient with thrombocytopenia should not use alcohol-based mouthwashes because alcohol-based mouthwashes will dry the mouth and increase bleeding. Patients with thrombocytopenia should drink plenty of fluids to prevent constipation. Patients with thrombocytopenia should shave using an electric razor, not blades, to prevent the risk for injury. Patients with thrombocytopenia should use a soft-bristle toothbrush to prevent gum injury.
Using alcohol based mouthwashes twice a day -A patient with thrombocytopenia should not use alcohol-based mouthwashes because alcohol-based mouthwashes will dry the mouth and increase bleeding. Patients with thrombocytopenia should drink plenty of fluids to prevent constipation. Patients with thrombocytopenia should shave using an electric razor, not blades, to prevent the risk for injury. Patients with thrombocytopenia should use a soft-bristle toothbrush to prevent gum injury.
The nurse is assessing laboratory reports that include the red blood cell indices of four patients in a clinical care setting. Which patient's red blood cell indices reflect microcytosis?
less than 80 MCV -The normal value for MCV is 80 to 100 fL and the normal value for MCH is 27 to 34 pg. Microcytosis is a condition in which red blood cells are unusually small. Low MCV or low MCH values indicate microcytosis or hypochromia. Therefore, the red blood cell indices of patient 3 with an MCH value of 25 pg and MCV value of 76 fL indicate microcytosis. Patient 1 has an MCH of 27 pg and MCV of 85 fL, which are within the normal range and do not indicate microcytosis. Patient 2 has an MCH of 30 pg and MCV of 80 fL, which are within the normal range. Patient 4 has an MCH of 40 pg and MCV of 105 fL, higher than the normal range. Therefore, this indicates macrocytosis.
