*Chapter 40: Care of Patients with Hematologic Problems

A nurse is caring for four clients with leukemia. After hand-off report, which client should the nurse see first? a. Client who had two bloody diarrhea stools this morning b. Client who has been premedicated for nausea prior to chemotherapy c. Client with a respiratory rate change from 18 to 22 breaths/min d. Client with an unchanged lesion to the lower right lateral malleolus

ANS: A The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI) tract and should be assessed first. The client with the change in respiratory rate may have an infection or worsening anemia and should be seen next. The other two clients are not a priority at this time. DIF: Applying/Application REF: 819

A client presents to the emergency department in sickle cell crisis. What intervention by the nurse takes priority? a. Administer oxygen. b. Apply an oximetry probe. c. Give pain medication. d. Start an IV line.

ANS: A All actions are appropriate, but remembering the ABCs, oxygen would come first. The main problem in a sickle cell crisis is tissue and organ hypoxia, so providing oxygen helps halt the process. DIF: Applying/Application REF: 812

A nurse caring for a client with sickle cell disease (SCD) reviews the clients laboratory work. Which finding should the nurse report to the provider? a. Creatinine: 2.9 mg/dL b. Hematocrit: 30% c. Sodium: 147 mEq/L d. White blood cell count: 12,000/mm3

ANS: A An elevated creatinine indicates kidney damage, which occurs in SCD. A hematocrit level of 30% is an expected finding, as is a slightly elevated white blood cell count. A sodium level of 147 mEq/L, although slightly high, is not concerning. DIF: Applying/Application REF: 811

A client in sickle cell crisis is dehydrated and in the emergency department. The nurse plans to start an IV. Which fluid choice is best? a. 0.45% normal saline b. 0.9% normal saline c. Dextrose 50% (D50) d. Lactated Ringers solution

ANS: A Because clients in sickle cell crisis are often dehydrated, the fluid of choice is a hypotonic solution such as 0.45% normal saline. 0.9% normal saline and lactated Ringers solution are isotonic. D50 is hypertonic and not used for hydration. DIF: Applying/Application REF: 812

A client hospitalized with sickle cell crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe the client is drug seeking. When the client requests pain medication, what action by the nurse is best? a. Give the client pain medication if it is time for another dose. b. Instruct the client not to request pain medication too early. c. Request the provider leave a prescription for a placebo. d. Tell the client it is too early to have more pain medication.

ANS: A Clients with sickle cell crisis often have severe pain that is managed with up to 48 hours of IV opioid analgesics. Even if the client is addicted and drug seeking, he or she is still in extreme pain. If the client can receive another dose of medication, the nurse should provide it. The other options are judgmental and do not address the clients pain. Giving placebos is unethical. DIF: Applying/Application REF: 811

The nurse is caring for a client with leukemia who has the priority problem of fatigue. What action by the client best indicates that an important goal for this problem has been met? a. Doing activities of daily living (ADLs) using rest periods b. Helping plan a daily activity schedule c. Requesting a sleeping pill at night d. Telling visitors to leave when fatigued

ANS: A Fatigue is a common problem for clients with leukemia. This client is managing his or her own ADLs using rest periods, which indicates an understanding of fatigue and how to control it. Helping to plan an activity schedule is a lesser indicator. Requesting a sleeping pill does not help control fatigue during the day. Asking visitors to leave when tired is another lesser indicator. Managing ADLs using rest periods demonstrates the most comprehensive management strategy. DIF: Evaluating/Synthesis REF: 818

A client has Crohns disease. What type of anemia is this client most at risk for developing? a. Folic acid deficiency b. Fanconis anemia c. Hemolytic anemia d. Vitamin B12 anemia

ANS: A Malabsorption syndromes such as Crohns disease leave a client prone to folic acid deficiency. Fanconis anemia, hemolytic anemia, and vitamin B12 anemia are not related to Crohns disease. DIF: Remembering/Knowledge REF: 814

A client has been admitted after sustaining a humerus fracture that occurred when picking up the family cat. What test result would the nurse correlate to this condition? a. Bence-Jones protein in urine b. Epstein-Barr virus: positive c. Hemoglobin: 18 mg/dL d. Red blood cell count: 8.2/mm3

ANS: A This client has possible multiple myeloma. A positive Bence-Jones protein finding would correlate with this condition. The Epstein-Barr virus is a herpesvirus that causes infectious mononucleosis and some cancers. A hemoglobin of 18 mg/dL is slightly high for a male and somewhat high for a female; this can be caused by several conditions, and further information would be needed to correlate this value with a specific medical condition. A red blood cell count of 8.2/mm3 is also high, but again, more information would be needed to correlate this finding with a specific medical condition. DIF: Applying/Application REF: 829

A client has a platelet count of 9000/mm3. The nurse finds the client confused and mumbling. What action takes priority? a. Calling the Rapid Response Team b. Delegating taking a set of vital signs c. Instituting bleeding precautions d. Placing the client on bedrest

ANS: A With a platelet count this low, the client is at high risk of spontaneous bleeding. The most disastrous complication would be intracranial bleeding. The nurse needs to call the Rapid Response Team as this client has manifestations of a sudden neurologic change. The nurse should not delegate the vital signs as the client is no longer stable. Bleeding precautions will not address the immediate situation. Placing the client on bedrest or putting the client back into bed is important, but the critical action is to call for immediate medical attention. DIF: Applying/Application REF: 830

A client has frequent hospitalizations for leukemia and is worried about functioning as a parent to four small children. What action by the nurse would be most helpful? a. Assist the client to make sick day plans for household responsibilities. b. Determine if there are family members or friends who can help the client. c. Help the client inform friends and family that they will have to help out. d. Refer the client to a social worker in order to investigate respite child care.

ANS: A While all options are reasonable choices, the best option is to help the client make sick day plans, as that is more comprehensive and inclusive than the other options, which focus on a single item. DIF: Applying/Application REF: 825

A nurse is preparing to administer a blood transfusion to an older adult. Understanding age-related changes, what alterations in the usual protocol are necessary for the nurse to implement? (Select all that apply.) a. Assess vital signs more often. b. Hold other IV fluids running. c. Premedicate to prevent reactions. d. Transfuse smaller bags of blood. e. Transfuse each unit over 8 hours.

ANS: A, B The older adult needs vital signs monitored as often as every 15 minutes for the duration of the transfusion because changes may be the only indication of a transfusion-related problem. To prevent fluid overload, the nurse obtains a prescription to hold other running IV fluids during the transfusion. The other options are not warranted. DIF: Remembering/Knowledge REF: 833

A student nurse is helping a registered nurse with a blood transfusion. Which actions by the student are most appropriate? (Select all that apply.) a. Hanging the blood product using normal saline and a filtered tubing set b. Taking a full set of vital signs prior to starting the blood transfusion c. Telling the client someone will remain at the bedside for the first 5 minutes d. Using gloves to start the clients IV if needed and to handle the blood product e. Verifying the clients identity, and checking blood compatibility and expiration time

ANS: A, B, D Correct actions prior to beginning a blood transfusion include hanging the product with saline and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using gloves. Someone stays with the client for the first 15 to 30 minutes of the transfusion. Two registered nurses must verify the clients identity and blood compatibility. DIF: Applying/Application REF: 832

A client has heparin-induced thrombocytopenia (HIT). The student nurse asks how this is treated. About what drugs does the nurse instructor teach? (Select all that apply.) a. Argatroban (Argatroban) b. Bivalirudin (Angiomax) c. Clopidogrel (Plavix) d. Lepirudin (Refludan) e. Methylprednisolone (Solu-Medrol)

ANS: A, B, D The standard drugs used to treat HIT are argatroban, bivalirudin, and lepirudin. The other drugs are not used. Clopidogrel is an antiplatelet agent used to reduce the likelihood of stroke or myocardial infarction. Methylprednisolone is a steroid used to reduce inflammation. DIF: Understanding/Comprehension REF: 831

A nurse working with clients with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factors should clients be taught to avoid? (Select all that apply.) a. Dehydration b. Exercise c. Extreme stress d. High altitudes e. Pregnancy

ANS: A, C, D, E Several factors cause red blood cells to sickle in SCD, including dehydration, extreme stress, high altitudes, and pregnancy. Strenuous exercise can also cause sickling, but not unless it is very vigorous. DIF: Remembering/Knowledge REF: 809 KEY: Hematologic system| patient education|

A student studying leukemias learns the risk factors for developing this disorder. Which risk factors does this include? (Select all that apply.) a. Chemical exposure b. Genetically modified foods c. Ionizing radiation exposure d. Vaccinations e. Viral infections

ANS: A, C, E Chemical and ionizing radiation exposure and viral infections are known risk factors for developing leukemia. Eating genetically modified food and receiving vaccinations are not known risk factors. DIF: Remembering/Knowledge REF: 817

A student nurse is learning about blood transfusion compatibilities. What information does this include? (Select all that apply.) a. Donor blood type A can donate to recipient blood type AB. b. Donor blood type B can donate to recipient blood type O. c. Donor blood type AB can donate to anyone. d. Donor blood type O can donate to anyone. e. Donor blood type A can donate to recipient blood type B.

ANS: A, D Blood type A can be donated to people who have blood types A or AB. Blood type O can be given to anyone. Blood type B can be donated to people who have blood types B or AB. Blood type AB can only go to recipients with blood type AB. DIF: Remembering/Knowledge REF: 834

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client should the nurse see first? a. Client with a blood pressure of 180/98 mm Hg b. Client who reports shortness of breath c. Client who reports calf tenderness and swelling d. Client with a swollen and painful left great toe

ANS: B Clients with polycythemia vera often have clotting abnormalities due to the hyperviscous blood with sluggish flow. The client reporting shortness of breath may have a pulmonary embolism and should be seen first. The client with a swollen calf may have a deep vein thrombosis and should be seen next. High blood pressure and gout symptoms are common findings with this disorder. DIF: Applying/Application REF: 815

A nurse is preparing to administer a blood transfusion. What action is most important? a. Correctly identifying client using two identifiers b. Ensuring informed consent is obtained if required c. Hanging the blood product with Ringers lactate d. Staying with the client for the entire transfusion

ANS: B If the facility requires informed consent for transfusions, this action is most important because it precedes the other actions taken during the transfusion. Correctly identifying the client and blood product is a National Patient Safety Goal, and is the most important action after obtaining informed consent. Ringers lactate is not used to transfuse blood. The nurse does not need to stay with the client for the duration of the transfusion. DIF: Applying/Application REF: 815

The family of a neutropenic client reports the client is not acting right. What action by the nurse is the priority? a. Ask the client about pain. b. Assess the client for infection. c. Delegate taking a set of vital signs. d. Look at todays laboratory results.

ANS: B Neutropenic clients often do not have classic manifestations of infection, but infection is the most common cause of death in neutropenic clients. The nurse should assess for infection. The nurse should assess for pain but this is not the priority. The nurse should take the clients vital signs instead of delegating them since the client has had a change in status. Laboratory results may be inconclusive. DIF: Applying/Application REF: 819

A client admitted for sickle cell crisis is distraught after learning her child also has the disease. What response by the nurse is best? a. Both you and the father are equally responsible for passing it on. b. I can see you are upset. I can stay here with you a while if you like. c. Its not your fault; there is no way to know who will have this disease. d. There are many good treatments for sickle cell disease these days.

ANS: B The best response is for the nurse to offer self, a therapeutic communication technique that uses presence. Attempting to assign blame to both parents will not help the client feel better. There is genetic testing available, so it is inaccurate to state there is no way to know who will have the disease. Stating that good treatments exist belittles the clients feelings. REF: 813

A client receiving a blood transfusion develops anxiety and low back pain. After stopping the transfusion, what action by the nurse is most important? a. Documenting the events in the clients medical record b. Double-checking the client and blood product identification c. Placing the client on strict bedrest until the pain subsides d. Reviewing the clients medical record for known allergies

ANS: B This client had a hemolytic transfusion reaction, most commonly caused by blood type or Rh incompatibility. The nurse should double-check all identifying information for both the client and blood type. Documentation occurs after the client is stable. Bedrest may or may not be needed. Allergies to medications or environmental items is not related. DIF: Analyzing/Analysis REF: 833

A client has a serum ferritin level of 8 ng/mL and microcytic red blood cells. What action by the nurse is best? a. Encourage high-protein foods. b. Perform a Hemoccult test on the clients stools. c. Offer frequent oral care. d. Prepare to administer cobalamin (vitamin B12).

ANS: B This client has laboratory findings indicative of iron deficiency anemia. The most common cause of this disorder is blood loss, often from the GI tract. The nurse should perform a Hemoccult test on the clients stools. High-protein foods may help the condition, but dietary interventions take time to work. That still does not determine the cause. Frequent oral care is not related. Cobalamin injections are for pernicious anemia. DIF: Applying/Application REF: 814

A client has Hodgkins lymphoma, Ann Arbor stage Ib. For what manifestations should the nurse assess the client? (Select all that apply.) a. Headaches b. Night sweats c. Persistent fever d. Urinary frequency e. Weight loss

ANS: B, C, E In this stage, the disease is located in a single lymph node region or a single nonlymph node site. The client displays night sweats, persistent fever, and weight loss. Headache and urinary problems are not related. DIF: Understanding/Comprehension REF: 827

A client with chronic anemia has had many blood transfusions. What medications does the nurse anticipate teaching the client about adding to the regimen? (Select all that apply.) a. Azacitidine (Vidaza) b. Darbepoetin alfa (Aranesp) c. Decitabine (Dacogen) d. Epoetin alfa (Epogen) e. Methylprednisolone (Solu-Medrol)

ANS: B, D Darbepoetin alfa and epoetin alfa are both red blood cell colony-stimulating factors that will help increase the production of red blood cells. Azacitidine and decitabine are used for myelodysplastic syndromes. Methylprednisolone is a steroid and would not be used for this problem. DIF: Remembering/Knowledge REF: 816

A nurse is caring for a young male client with lymphoma who is to begin treatment. What teaching topic is a priority? a. Genetic testing b. Infection prevention c. Sperm banking d. Treatment options

ANS: C All teaching topics are important to the client with lymphoma, but for a young male, sperm banking is of particular concern if the client is going to have radiation to the lower abdomen or pelvis. DIF: Understanding/Comprehension REF: 827

A client has a sickle cell crisis with extreme lower extremity pain. What comfort measure does the nurse delegate to the unlicensed assistive personnel (UAP)? a. Apply ice packs to the clients legs. b. Elevate the clients legs on pillows. c. Keep the lower extremities warm. d. Place elastic bandage wraps on the clients legs.

ANS: C During a sickle cell crisis, the tissue distal to the occlusion has decreased blood flow and ischemia, leading to pain. Due to decreased blood flow, the clients legs will be cool or cold. The UAP can attempt to keep the clients legs warm. Ice and elevation will further decrease perfusion. Elastic bandage wraps are not indicated and may constrict perfusion in the legs. DIF: Applying/Application REF: 812

A nurse is caring for a client who is about to receive a bone marrow transplant. To best help the client cope with the long recovery period, what action by the nurse is best? a. Arrange a visitation schedule among friends and family. b. Explain that this process is difficult but must be endured. c. Help the client find things to hope for each day of recovery. d. Provide plenty of diversionary activities for this time.

ANS: C Providing hope is an essential nursing function during treatment for any disease process, but especially during the recovery period after bone marrow transplantation, which can take up to 3 weeks. The nurse can help the client look ahead to the recovery period and identify things to hope for during this time. Visitors are important to clients, but may pose an infection risk. Telling the client the recovery period must be endured does not acknowledge his or her feelings. Diversionary activities are important, but not as important as instilling hope. DIF: Applying/Application REF: 823

A client has thrombocytopenia. What client statement indicates the client understands self-management of this condition? a. I brush and use dental floss every day. b. I chew hard candy for my dry mouth. c. I usually put ice on bumps or bruises. d. Nonslip socks are best when I walk.

ANS: C The client should be taught to apply ice to areas of minor trauma. Flossing is not recommended. Hard foods should be avoided. The client should wear well-fitting shoes when ambulating. DIF: Evaluating/Synthesis REF: 824

A client has been treated for a deep vein thrombus and today presents to the clinic with petechiae. Laboratory results show a platelet count of 42,000/mm3. The nurse reviews the clients medication list to determine if the client is taking which drug? a. Enoxaparin (Lovenox) b. Salicylates (aspirin) c. Unfractionated heparin d. Warfarin (Coumadin)

ANS: C This client has manifestations of heparin-induced thrombocytopenia. Enoxaparin, salicylates, and warfarin do not cause this condition. DIF: Applying/Application REF: 831

A client has received a bone marrow transplant and is waiting for engraftment. What actions by the nurse are most appropriate? (Select all that apply.) a. Not allowing any visitors until engraftment b. Limiting the protein in the clients diet c. Placing the client in protective precautions d. Teaching visitors appropriate hand hygiene e. Telling visitors not to bring live flowers or plants

ANS: C, D, E The client waiting for engraftment after bone marrow transplant has no white cells to protect him or her against infection. The client is on protective precautions and visitors are taught hand hygiene. No fresh flowers or plants are allowed due to the standing water in the vase or container that may harbor organisms. Limiting protein is not a healthy option and will not promote engraftment. REF: 823

A client has a platelet count of 25,000/mm3. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Assist with oral hygiene using a firm toothbrush. b. Give the client an enema if he or she is constipated. c. Help the client choose soft foods from the menu. d. Shave the male client with an electric razor. e. Use a lift sheet when needed to re-position the client.

ANS: C, D, E This client has thrombocytopenia and requires bleeding precautions. These include oral hygiene with a softbristled toothbrush or swabs, avoiding rectal trauma, eating soft foods, shaving with an electric razor, and using a lift sheet to re-position the client. DIF: Applying/Application REF: 824

A client with multiple myeloma demonstrates worsening bone density on diagnostic scans. About what drug does the nurse plan to teach this client? a. Bortezomib (Velcade) b. Dexamethasone (Decadron) c. Thalidomide (Thalomid) d. Zoledronic acid (Zometa)

ANS: D All the options are drugs used to treat multiple myeloma, but the drug used specifically for bone manifestations is zoledronic acid (Zometa), which is a bisphosphonate. This drug class inhibits bone resorption and is used to treat osteoporosis as well. DIF: Applying/Application REF: 829

A nursing student is struggling to understand the process of graft-versus-host disease. What explanation by the nurse instructor is best? a. Because of immunosuppression, the donor cells take over. b. Its like a transfusion reaction because no perfect matches exist. c. The clients cells are fighting donor cells for dominance. d. The donors cells are actually attacking the clients cells.

ANS: D Graft versus host disease is an autoimmune-type process in which the donor cells recognize the clients cells as foreign and begin attacking them. The other answers are not accurate. DIF: Understanding/Comprehension REF: 823

A nursing student is caring for a client with leukemia. The student asks why the client is still at risk for infection when the clients white blood cell count (WBC) is high. What response by the registered nurse is best? a. If the WBCs are high, there already is an infection present. b. The client is in a blast crisis and has too many WBCs. c. There must be a mistake; the WBCs should be very low. d. Those WBCs are abnormal and dont provide protection.

ANS: D In leukemia, the WBCs are abnormal and do not provide protection to the client against infection. The other statements are not accurate. DIF: Understanding/Comprehension REF: 818

A nurse is preparing to hang a blood transfusion. Which action is most important? a. Documenting the transfusion b. Placing the client on NPO status c. Placing the client in isolation d. Putting on a pair of gloves

ANS: D To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the blood. Documentation is important but not the priority at this point. NPO status and isolation are not needed. DIF: Applying/Application REF: 831

A client with autoimmune idiopathic thrombocytopenic purpura (ITP) has had a splenectomy and returned to the surgical unit 2 hours ago. The nurse assesses the client and finds the abdominal dressing saturated with blood. What action is most important? a. Preparing to administer a blood transfusion b. Reinforcing the dressing and documenting findings c. Removing the dressing and assessing the surgical site d. Taking a set of vital signs and notifying the surgeon

ANS: D While some bloody drainage on a new surgical dressing is expected, a saturated dressing is not. This client is already at high risk of bleeding due to the ITP. The nurse should assess vital signs for shock and notify the surgeon immediately. The client may or may not need a transfusion. Reinforcing the dressing is an appropriate action, but the nurse needs to do more than document afterward. Removing the dressing increases the risk of infection; plus, it is not needed since the nurse knows where the bleeding is coming from. DIF: Applying/Application REF: 830

A client with sickle cell disease (SCD) takes hydroxyurea (Droxia). The client presents to the clinic reporting an increase in fatigue. What laboratory result should the nurse report immediately? a. Hematocrit: 25% b. Hemoglobin: 9.2 mg/dL c. Potassium: 3.2 mEq/L d. White blood cell count: 38,000/mm3

ANS: D Although individuals with SCD often have elevated white blood cell (WBC) counts, this extreme elevation could indicate leukemia, a complication of taking hydroxyurea. The nurse should report this finding immediately. Alternatively, it could indicate infection, a serious problem for clients with SCD. Hematocrit and hemoglobin levels are normally low in people with SCD. The potassium level, while slightly low, is not as worrisome as the WBCs. DIF: Analyzing/Analysis REF: 816

The nurse assesses a clients oral cavity and makes the discovery shown in the photo below: What action by the nurse is most appropriate? a. Encourage the client to have genetic testing. b. Instruct the client on high-fiber foods. c. Place the client in protective precautions. d. Teach the client about cobalamin therapy.

ANS: D This condition is known as glossitis, and is characteristic of B12 anemia. If the anemia is a pernicious anemia, it is treated with cobalamin. Genetic testing is not a priority for this condition. The client does not need highfiber foods or protective precautions. DIF: Applying/Application REF: 814