Chapter 40: Care of Patients with Hematologic Problems

The nurse is infusing platelets to a client who is scheduled for a hematopoietic stem cell transplant. What procedure does the nurse follow for administering this blood product? A. Infuse the transfusion over a 15- to 30-minute period. B. Set up the infusion with the standard transfusion Y tubing. C. Give intravenous corticosteroids before starting the transfusion. D. Allow the platelets to stabilize at the client's bedside for 30 minutes.

A. Infuse the transfusion over a 15- to 30-minute period. The procedure the nurse follows to administer platelets to a hematopoietic stem cell transplant is to infuse the transfusion over a 15-to-30-minute period. The volume of platelets—200 or 300 mL (standard amount)—needs to be infused rapidly over a 15- to 30-minute period.A special transfusion set with a smaller filter and shorter tubing is used to get the platelets into the client quickly and efficiently. Administering steroids is not standard practice in administering platelets. Platelets must be administered immediately after they are received because they are considered to be quite fragile.

Which task is appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP) working on a medical-surgical unit? A. Obtain vital signs on a client receiving a blood transfusion B. Assist a client with folic acid deficiency in making diet choices C. Administer erythropoietin to a client with myelodysplastic syndrome D. Assess skin integrity on an anemic client who fell during ambulation

A. Obtain vital signs on a client receiving a blood transfusion The appropriate task for the nurse to delegate to a UAP is obtaining vital signs on a client receiving a blood transfusion. This activity is within the scope of practice for UAPs.Assisting with prescribed diet choices, administering medication, and assessing clients are complex actions that must be done by licensed nurses.

The nurse is assessing several clients who are receiving transfusions of blood components. Which assessment finding requires immediate action by the nurse? A. Respiratory rate of 36 breaths/min in a client receiving red blood cells B. Temperature of 99.1°F (37.3°C) for a client with a platelet transfusion C. Sleepiness in a client who received diphenhydramine (Benadryl) as a premedication D. A partial thromboplastin time (PTT) that is 1.2 times normal in a client who received a transfusion of fresh-frozen plasma (FFP)

A. Respiratory rate of 36 breaths/min in a client receiving red blood cells The assessment finding that requires immediate action by the nurse is a respiratory rate of 36 breaths/min in a client receiving red blood cells. An increased respiratory rate indicates a possible hemolytic transfusion reaction. The nurse must quickly stop the transfusion and assess the client further.Temperature elevations are not an indication of an allergic reaction to a platelet transfusion, although the nurse may administer acetaminophen (Tylenol) to decrease the fever. Sleepiness is expected when Benadryl is administered. Because FFP is not usually given until the PTT is 1.5 times above normal, a PTT that is 1.2 times normal indicates that the FFP has had the desired response.

A client who is receiving a blood transfusion suddenly tells the nurse, "I don't feel right!" What is the nurse's first action? A. Stop the transfusion. B. Call the Rapid Response Team. C. Slow the infusion rate of the transfusion. D. Obtain vital signs and continue to monitor.

A. Stop the transfusion. The nurse's first action when a client receiving a blood transfusion says, "I don't feel right," is to stop the transfusion. The client may be experiencing a transfusion reaction, so the nurse must stop the transfusion immediately.Calling the Rapid Response Team or obtaining vital signs is not the first thing that must be done. The nurse would not slow the infusion rate but would stop it altogether.

The nurse is mentoring a recent graduate registered nurse (RN) about administering blood and blood products. What action does the nurse perform before starting the transfusion? A. Verify with another RN all of the data on blood products. B. Use a 22-gauge needle to obtain venous access when starting the infusion. C. Remain with the client who is receiving the blood for the first 5 minutes of the infusion. D. Obtain the client's initial set of vital signs (VS) within the first 10 minutes of the infusion.

A. Verify with another RN all of the data on blood products. Before administering blood and blood products, the nurse must verify with another RN all of the data on blood products. All data are checked by two RNs. Human error is the most common cause of ABO incompatibilities when administering blood and blood products.A 20-gauge needle (or a central line catheter) is used. The 22-gauge needle is too small. Initial VS must be recorded before the start of infusion of blood, not after it has begun. The nurse remains with the client for the first 15 to 30 minutes (not 5) of the infusion. This is the period when any transfusion reactions are likely to happen.

1. An 82-year-oldclient with anemia is prescribed 2 units of whole blood. Which assessment findings cause the nurse to discontinue the transfusion because it is unsafe for the client? SELECT ALL THAT APPLY A. Hypotension B. Hypertension C. Decreased pallor D. Rapid, bounding pulse E. Flattened superficial veins F. Capillary refill less than 3 seconds

ANS: A. Hypotension B. Hypertension D. Rapid, bounding pulse The assessment findings that are unsafe for the nurse to continue the blood transfusion for the client are: hypotension, hypertension, and rapid, bounding pulse. In an older adult receiving a transfusion, low blood pressure is a sign of a transfusion reaction, hypertension is a sign of overload, and a rapid and bounding pulse is a sign of fluid overload. In this scenario, 2 units, or about a liter of fluid, could be problematic.Increased (not decreased) pallor and cyanosis are signs of a transfusion reaction, while swollen (not flattened) superficial veins are present in fluid overload in older adult clients receiving transfusions. Capillary refill time that is less than 3 seconds is considered to be normal and would not pose a problem.

A client with thrombocytopenia is being discharged. Which instruction would the nurse include in a teaching plan for this client? A. "Avoid large crowds." B. "Use a soft-bristled toothbrush." C. "Drink at least 2 L of fluid per day." D. "Elevate your lower extremities when sitting."

B. "Use a soft-bristled toothbrush." Using a soft-bristled toothbrush reduces the risk for bleeding in the client with thrombocytopenia.Avoiding large crowds reduces the risk for infection but is not specific to the client with thrombocytopenia. Increased fluid intake reduces the risk for dehydration but is not particularly relevant to the client with thrombocytopenia. Elevating extremities reduces the risk for dependent edema but is not specific to the client with thrombocytopenia.

The nurse is transfusing 2 units of packed red blood cells to a postoperative client. What electrolyte imbalance would the nurse monitor for after the blood transfusion? A. Hyponatremia B. Hyperkalemia C. Hypercalcemia D. Hypomagnesemia

B. Hyperkalemia The electrolyte imbalance the nurse needs to monitor after transfusing 2 units of blood to a postoperative client is hyperkalemia. During transfusion, some cells are damaged. These cells release potassium, thus raising the client's serum potassium level (hyperkalemia). This complication is especially common with packed cells and whole-blood products.High serum calcium levels, low magnesium levels, or low sodium levels are not expected with blood transfusions.

The nurse is transfusing a unit of whole blood to a client when the primary health care provider prescribes "Furosemide (Lasix) 20 mg IV push." Which intervention would the nurse perform? A. Piggyback the furosemide into the infusing blood. B. Give furosemide to the client intramuscularly (IM). C. Administer the furosemide after completion of the transfusion. D. Add furosemide to the normal saline that is infusing with the blood.

C. Administer the furosemide after completion of the transfusion. Completing the transfusion before administering furosemide is the best course of action in this scenario.Drugs are not to be administered with infusing blood products, because they can interact with the blood, causing risks for the client. Changing the admission route is not a nursing decision. Stopping the infusing blood to administer the drug and then restarting it is also not the best decision.

1. The nurse assesses the client with which hematologic condition first? A. A 32-year-old with pernicious anemia who needs a vitamin B12 injection B. A 67-year-old with acute myelocytic leukemia with petechiae on both legs C. An 81-year-old with thrombocytopenia and an increase in abdominal girth D. A 40-year-old with iron deficiency anemia who needs a Z-track iron injection

C. An 81-year-old with thrombocytopenia and an increase in abdominal girth The nurse needs to first assess the 81-year-old client with thrombocytopenia and an increase in abdominal girth. An increase in abdominal girth in a client with thrombocytopenia indicates possible hemorrhage, and warrants further assessment immediately.The 32-year-old with pernicious anemia, the 67-year-old with acute myelocytic leukemia, and the 40-year-old with iron deficiency anemia do not indicate any acute complications, so the nurse can assess them after assessing the client with thrombocytopenia.

The nurse performs an assessment on a newly admitted client with thrombocytopenia. Which assessment finding requires immediate intervention by the nurse? A. Reports of pain B. Increased temperature C. Bleeding from the nose D. Decreased urine output

C. Bleeding from the nose The assessment finding on a newly admitted client with thrombocytopenia that needs immediate intervention by the nurse is bleeding from the nose. The client with thrombocytopenia has a high risk for bleeding. The nosebleed would be attended to immediately.The client's report of pain, decreased urine output, and increased temperature are not the highest priority.

Which client is at greatest risk for experiencing a hemolytic transfusion reaction? A. A 42-year-old client with allergies B. A 78-year-old client with arthritis C. A 58-year-old immune-suppressed client D. A 34-year-old client with type O blood

D. A 34-year-old client with type O blood The client at greatest risk for experiencing a hemolytic transfusion reaction is the 34-year-old client with type O blood. Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood that contains antigens different from the client's own antigens is infused, antigen-antibody complexes are formed in the client's blood. Type O is considered the universal donor, but not the universal recipient.The client with allergies would be most susceptible to an allergic transfusion reaction. The older adult client with arthritis would be most susceptible to circulatory overload. The immune-suppressed client would be most susceptible to a transfusion-associated graft-versus-host disease.

Which nursing intervention most effectively protects a client with thrombocytopenia? A. Take rectal temperatures B. Avoid the use of dentures C. Apply warm compresses on trauma sites D. Encourage the use of an electric shaver

D. Encourage the use of an electric shaver The most effective nursing intervention that protects a client with thrombocytopenia is encouraging the client to use an electric shaver. This client must be advised to use an electric shaver instead of a razor. Any small cuts or nicks can cause problems because of the prolonged clotting time.To prevent rectal trauma, rectal thermometers would not be used. Oral or tympanic temperatures would be taken. Dentures may be used by clients with thrombocytopenia as long as they fit properly and do not rub. Ice (not heat) would be applied to areas of trauma.

The nurse is to administer packed red blood cells to a client. How does the nurse ensure proper client identification? A. Ask the client's name B. Check the client's armband C. Verify the client's room number D. Review all information with another registered nurse (RN)

D. Review all information with another registered nurse (RN) With another registered nurse, all information must be reviewed. This process includes verifying the client by name and number, checking blood compatibility, and noting the expiration time. Human error is the most common cause of ABO incompatibility reactions, even for experienced nurses.Asking the client's name and checking the client's armband are not adequate for identifying the client before transfusion therapy. Using the room number to verify client identification is never appropriate

36. 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)

a. Argatroban (Argatroban) b. Bivalirudin (Angiomax) d. Lepirudin (Refludan)

35. 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.

a. Assess vital signs more often. b. Hold other IV fluids running. 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.

17. 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

a. Calling the Rapid Response Team

33. 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.

a. Donor blood type A can donate to recipient blood type AB. d. Donor blood type O can donate to anyone. 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.

32. 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

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 d. Using gloves to start the clients IV if needed and to handle the blood product

20. 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

b. Double-checking the client and blood product identification

18. 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

b. Ensuring informed consent is obtained if required

5. 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).

b. Perform a Hemoccult test on the clients stools.

31. 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.

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.

10. 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.

c. Help the client find things to hope for each day of recovery.

21. 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.

c. I usually put ice on bumps or bruises.

37. 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

c. Placing the client in protective precautions d. Teaching visitors appropriate hand hygiene e. Telling visitors not to bring live flowers or plants

27. 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)

c. Unfractionated heparin

19. 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

d. Putting on a pair of gloves

16. 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

d. Taking a set of vital signs and notifying the surgeon

11. 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.

d. The donors cells are actually attacking the clients cells.