Chapter 33: Management of Patients with Nonmalignant Hematologic Disorders

D-dimer

Test to measure fibrin breakdown; considered more specific than fibrin degradation products in the diagnosis of disseminated intravascular coagulation

Poikilocytosis

Variation in shape of RBCs

When teaching a patient with iron deficiency anemia about appropriate food choices, the nurse will encourage the patient to increase the dietary intake of which of the following foods? a) Fruits high in vitamin C, such as organs and grapefruits b) Berries and orange vegetables c) Beans, dried fruits, and leafy green vegetables d) Dairy products

c) Beans, dried fruits, and leafy green vegetables Food sources high in iron include organ meats (e.g., beef or calf's liver, chicken liver), other meats, beans (e.g., black, pinto, and garbanzo), leafy green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron.

A nurse is caring for a client with a history of GI bleeding, sickle cell anemia, and a platelet count of 22,000/μl. The client, who is dehydrated and receiving dextrose 5% in half-normal saline solution at 150 ml/hour, complains of severe bone pain and is scheduled to receive a dose of morphine sulfate. For which administration route should the nurse question an order? a) Oral b) Subcutaneous (subQ) c) I.M. d) I.V.

c) I.M. A client with a platelet count of 22,000/μl bleeds easily. The nurse should avoid using the I.M. route because the area is highly vascular. The client may bleed readily when penetrated by a needle, and it may be difficult for the nurse to stop the bleeding. The client's existing I.V. access would be the best route, especially because I.V. morphine is effective almost immediately. Oral and subQ routes are preferred over I.M., but they're less effective for acute pain management than I.V.

A patient with sickle cell disease comes to the emergency department complaining of severe pain in the back, right hip, and right arm. What intervention is important for the nurse to provide? a) Administer aspirin b) Administer ibuprofen c) Begin oxygen at 2 L/M d) Start an intravenous line with dextrose 5% in 0.25 normal saline

d) Start an intravenous line with dextrose 5% in 0.25 normal saline Adequate hydration is important during a painful sickling episode. Oral hydration is acceptable if the patient can maintain adequate fluid intake; IV hydration with dextrose 5% in water (D5W) or dextrose 5% in 0.25 normal saline solution (3 L/m2/24 h) may be required for a sickle crisis. Supplemental oxygen may also be needed.

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) A hemolytic reaction to mismatched blood b) A hemolytic reaction caused by bacterial contamination of donor blood c) A hemolytic reaction to Rh-incompatible blood d) A hemolytic allergic reaction caused by an antigen reaction

d) 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, diarrhea, abdominal cramps and, possibly, shock.

Absolute neutrophil count

A calculation of the number of circulating neutrophils, derived from the total WBCs and the percentage of neutrophils counted in a microscope's visual field

A patient describes numbness in the arms and hands with a tingling sensation. The patient also frequently stumbles when walking. What vitamin deficiency does the nurse determine may cause some of these symptoms? a) B12 b) Thiamine c) Folate d) Iron

a) B12 The hematologic effects of vitamin B12 deficiency are accompanied by effects on other organ systems, particularly the gastrointestinal tract and nervous system. Patients with pernicious anemia may become confused; more often, they have paresthesias in the extremities (particularly numbness and tingling in the feet and lower legs). They may have difficulty maintaining their balance because of damage to the spinal cord, and they also lose position sense (proprioception).

A pregnant woman is hospitalized as the result of sickle-cell crisis. A finding that indicates the outcome has been achieved for this client is that the client a) Exhibits a temperature less than 100.3°F b) Reports joint pain less than 3 on a scale of 0 to 10 c) Describes the importance of staying cool d) Takes hydroxyurea (Hydrea) during her pregnancy

b) Reports joint pain less than 3 on a scale of 0 to 10 An expected outcome for a client experiencing a sickle-cell crisis is control of pain. Hydroxyurea is contraindicated in pregnancy because of the risk it poses for congenital abnormalities. An indication that the client is free from infection is exhibiting a normal temperature; 100.3°F is an elevated temperature. To minimize crises, the client needs to stay warm.

A client receiving a blood transfusion experiences an acute hemolytic reaction. Which nursing intervention is the most important? a) Immediately stop the transfusion, infuse dextrose 5% in water (D5W), and call the physician. b) Slow the transfusion and monitor the client closely. c) Immediately stop the transfusion, infuse normal saline solution, call the physician, and notify the blood bank. d) Stop the transfusion, notify the blood bank, and administer antihistamines.

c) 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.

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters? a) Platelet count, blood glucose levels, and white blood cell (WBC) count b) Thrombin time, calcium levels, and potassium levels c) Platelet count, prothrombin time, and partial thromboplastin time d) Fibrinogen level, WBC, and platelet count

c) 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.

You are caring for a client with thalassemia who is being transfused. What is your role during a transfusion? a) To administer vitamin B12 injections b) To assess for enlargement and tenderness over the liver and spleen c) To closely monitor the rate of administration d) To instruct the client to rest immediately if chest pain develops

c) 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.

A nurse on a hematology/oncology floor is caring for a client with aplastic anemia. Which of the following would not be included in the client's discharge instructions? a) Plan for frequent periods of rest. b) Avoid contact with family/friends who are sick. c) Use a disposable razor when shaving. d) Encourage frequent handwashing.

c) Use a disposable razor when shaving. People with aplastic anemia usually have insufficient erythrocytes, leukocytes, and platelets. Encourage behaviors that will lower the risk for bleeding. People with aplastic anemia usually have insufficient erythrocytes, leukocytes, and platelets. Avoiding contact with people who are sick reduces the risk of acquiring an infection. People with aplastic anemia usually have insufficient erythrocytes, leukocytes, and platelets. Handwashing reduces the risk of acquiring an infection. Anemia can cause fatigue and shortness of breath with even mild exertion.

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: a) to a standing position so he can urinate. b) to the bathroom. c) to the bedside commode. d) onto the bedpan.

d) 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.

Jeremiah, a 10-year-old boy with hemophilia, is a patient on the pediatric unit where you practice nursing. Jeremiah was admitted to your floor via the ED after sustaining an injury while playing outdoors with friends. Initially, he presented with severe bleeding but has since stabilized. Which of the following interventions will the nurse include in her care plan for Jeremiah? Select all that apply. a) Obtain an oral temperature to ensure accuracy. b) Support painful joints on pillows. c) Encourage client to use a soft toothbrush and rinse the mouth with warm water between and after meals. d) Eliminate aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs).

b) Support painful joints on pillows. c) Encourage client to use a soft toothbrush and rinse the mouth with warm water between and after meals. d) Eliminate aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). Interventions are implemented to reduce pain and discomfort and to prevent further bleeding episodes. NSAIDs and aspirin are eliminated because these drugs can increase bleeding tendencies. The nurse takes the temperature over the temporal artery or tympanically to avoid oral or rectal injuries and checks the urine and stools for signs of bleeding.

A patient with severe anemia is complaining of the following symptoms: tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Lab results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which of the following nursing diagnoses is most appropriate for this patient? a) Fatigue related to decreased hemoglobin and hematocrit b) Risk for falls related to complaints of dizziness c) Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit d) Imbalanced nutrition, less than body requirements, related to inadequate intake of essential nutrients

c) 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 patient was admitted to the hospital with the following lab values: hemoglobin 5 g/dL, abnormally shaped erythrocytes, leukocyte count 2000/mm3 with hypersegmented neutrophils and a platelet count of 48,000/mm3. The platelets appear abnormally large. A bone marrow biopsy was competed and revealed hyperplasia. Based on this information, the nurse determines that patient most likely has which of the following diagnoses? a) Thalassemia b) Sickle cell anemia c) Hemolytic anemia d) Folic acid deficiency

d) Folic acid deficiency Anemia caused by a deficiency of folic acid cause bone marrow and peripheral blood changes. The erythrocytes that are produced are abnormally large and are called megaloblastic red cells. Other cells derived from the myeloid stem cell are also abnormal. A bone marrow analysis reveals hyperplasia (abnormal increase in the number of cells). Pancytopenia (a decrease in all myeloid stem cell-derived cells) can develop. In advanced stages of disease, the hemoglobin value may be as low as 4 to 5 g/dL, the leukocyte count 2,000 to 3,000/mm3, and the platelet count less than 50,000/mm3. Cells that are released into the circulation are often abnormally shaped. The neutrophils are hypersegmented. The platelets may be abnormally large. The erythrocytes are abnormally shaped.

The thalassemias are a group of hereditary anemias characterized by which of the following? Select all that apply. a) Thrombocytopenia b) Hypochromia c) Hemolysis d) Anemia e) Extreme microcytosis

b) Hypochromia c) Hemolysis d) Anemia e) Extreme microcytosis The thalassemias are a group of hereditary anemias characterized by hypochromia, extreme microcytosis, destruction of blood elements (hemolysis), and variable degrees of anemia. Thrombocytopenia is not associated with thalassemias.

A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy? a) "I will receive parenteral vitamin B12 therapy monthly for 6 months to a year." b) "I will receive parenteral vitamin B12 therapy for the rest of my life." c) "I will receive parenteral vitamin B12 therapy until my signs and symptoms disappear." d) "I will receive parenteral vitamin B12 therapy until my vitamin B12 level returns to normal."

b) "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 client reports feeling tired, cold, and short of breath at times. Your assessment reveals tachycardia and reduced energy. What would you expect the physician to order? a) Chest radiograph b) Antibiotic c) ECG d) CBC

d) 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. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased.