ch20: hematology disorders
A client is receiving chemotherapy for acute myeloid leukemia and has poor nutritional intake. What is the first action the nurse should take? Ask, "Are you experiencing nausea?" Provide mouth care before each meal. Caution the client to chew carefully after administration of the prescribed lidocaine. Provide nutritional supplements in addition to a diet that has a soft texture and moderate temperature.
Ask, "Are you experiencing nausea?" All these options are things the nurse can do to assist the client to obtain better nutrition. The nurse first needs to assess the reason for poor nutritional intake. It could be because of nausea, in which case the nurse would implement interventions to address the client's nausea.
G-CSF (filgrastim) is prescribed for a client with bone marrow suppression. What medication administration teaching should the nurse provide to the client? Take this medication by mouth at bedtime each night. Do not eat before arriving to receive the intravenous administration of filgrastim. Assist the client in identifying appropriate subcutaneous injection sites. Filgrastim is taken intramuscularly on a weekly basis.
Assist the client in identifying appropriate subcutaneous injection sites. Filgrastim (Neupogen) is administered subcutaneously on a daily basis.
When teaching a client with iron deficiency anemia about appropriate food choices, the nurse encourages the client to increase the dietary intake of which foods? Berries and orange vegetables Fruits high in vitamin C, such as oranges and grapefruits Dairy products Beans, dried fruits, and leafy, green vegetables
Beans, dried fruits, and leafy, green vegetables Food sources high in iron include organ meats (e.g., beef or calf liver, chicken liver), other meats, beans (e.g., black, pinto, and garbanzo), leafy and 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 performing an initial assessment and notes the client's skin is a gray-tan color, especially on the scars of the client's arms. Which hematological condition does the nurse suspect? Polycythemia Thrombocytopenia Hemochromatosis Vitamin B12 deficiency
Hemochromatosis Hemochromatosis is an autosomal recessive disease of excessive iron absorption. This results in bronze or gray-tan skin, especially over scars. The other answer choices are hematological conditions; however, these do not cause the skin to turn a gray-tan color.
A nurse is caring for a client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client? Angina pectoris, double vision, and anorexia Sore tongue, dyspnea, and weight gain Pallor, tachycardia, and a sore tongue Pallor, bradycardia, and reduced pulse pressure
Pallor, tachycardia, and a sore tongue Pallor, tachycardia, and a sore tongue are all characteristic findings in pernicious anemia. Other clinical manifestations include anorexia; weight loss; a smooth, beefy red tongue; a wide pulse pressure; palpitations; angina pectoris; weakness; fatigue; and paresthesia of the hands and feet. Bradycardia, reduced pulse pressure, weight gain, and double vision aren't characteristic findings in pernicious anemia.
The nurse is teaching a client with acute lymphocytic leukemia (ALL) about therapy. What statement should be included in the plan of care? "The goal of therapy is palliation." "Intrathecal chemotherapy is used primarily as preventive therapy." "Side effects are rare with therapy." "Treatment is simple and consists of single-drug therapy."
"Intrathecal chemotherapy is used primarily as preventive therapy." Intrathecal chemotherapy is a key part of the treatment plan to prevent invasion of the central nervous system. The therapy uses multiple drugs, with many side effects. The goal of therapy is remission.
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 health care provider immediately because the client probably is experiencing which problem? A hemolytic reaction caused by bacterial contamination of donor blood A hemolytic allergic reaction caused by an antigen reaction A hemolytic reaction to mismatched blood A hemolytic reaction to Rh-incompatible blood
A hemolytic allergic reaction caused by an antigen reaction Hemolytic allergic reactions are fairly common and may cause chills, fever, urticaria, tachycardia, dyspnea, 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.
A female patient has a hemoglobin of 6.4 g/dL and is preparing to have a blood transfusion. Why would it be important for the nurse to obtain information about the patient's history of pregnancy prior to the transfusion? A high number of pregnancies can increase the risk of reaction. If the patient has never been pregnant, it increases the risk of reaction. If the patient has been pregnant, she may have developed allergies. Obtaining information about gravidity and parity is routine information for all female patients.
A high number of pregnancies can increase the risk of reaction. The patient history is an important component of the pretransfusion assessment to determine the history of previous transfusions as well as previous reactions to transfusion. The history should include the type of reaction, its manifestations, the interventions required, and whether any preventive interventions were used in subsequent transfusions. The nurse assesses the number of pregnancies a woman has had, because a high number can increase her risk of reaction due to antibodies developed from exposure to fetal circulation.
The nurse cares for a client with acute myeloid leukemia with severe bone pain. What pathophysiological concept does the nurse understand is the reason for the client's pain? Abnormal blood cells deposit in small vessels. Bone marrow expands. Lymph nodes expand. Abnormal blood cells crystalize.
Bone marrow expands. In acute myeloid leukemia, bone pain is caused when the bone marrow expands.
The nurse suspects that a client has multiple myeloma based on the client's major presenting symptom and the analysis of laboratory results. What classic symptom for multiple myeloma does the nurse assess for? Debilitating fatigue Bone pain in the back of the ribs Gradual muscle paralysis Severe thrombocytopenia
Bone pain in the back of the ribs Although patients can have asymptomatic bone involvement, the most common presenting symptom of multiple myeloma is bone pain, usually in the back or ribs. Unlike arthritic pain, the bone pain associated with myeloma increases with movement and decreases with rest; clients may report that they have less pain on awakening but the pain intensity increases during the day.
A client with polycythemia vera reports severe itching. What triggers does the nurse know can cause this distressing symptom? Select all that apply. Exposure to water of any temperature Allergic reaction to the red blood cell increase Aspirin Temperature change Alcohol consumption
Exposure to water of any temperature Temperature change Alcohol consumption Pruritus is very common, occurring in up to 70% of clients with polycythemia vera (Saini, Patnaik & Tefferi, 2010) and is one of the most distressing symptoms of this disease. It is triggered by contact with temperature change, alcohol consumption, or, more typically, exposure to water of any temperature but seems to be worse with exposure to hot water.
Which iron-rich foods should a nurse encourage an anemic client requiring iron therapy to eat? Lamb and peaches Cheese and bananas Shrimp and tomatoes Lobster and squash
Lamb and peaches Iron-rich foods include lamb and peaches. Shrimp, tomatoes, lobster, squash, cheese, and bananas aren't high in iron content.
During the review of morning laboratory values for a client reporting severe fatigue and a red, swollen tongue, the nurse suspects chronic, severe iron deficiency anemia based on which finding? Low ferritin level concentration Enlarged mean corpuscular volume (MCV) Elevated red blood cell (RBC) count Elevated hematocrit concentration
Low ferritin level concentration The most consistent indicator of iron deficiency anemia is a low ferritin level, which reflects low iron stores. As the anemia progresses, the MCV, which measures the size of the erythrocytes, also decreases. Hematocrit and RBC levels are also low in relation to the hemoglobin concentration. Ferritin is a protein inside your cells that stores iron. It allows your body to use the iron when it needs it. A ferritin test indirectly measures the amount of iron in your blood.
A nurse cares for a client with myelodysplastic syndrome (MDS). Which assessment finding does the nurse recognize is the most common finding with this condition? Hemolytic anemia Microcytic anemia Proliferative anemia Macrocytic anemia
Macrocytic anemia Macrocytic anemia is the most common symptom of MDS.
vDuring a routine assessment of a patient diagnosed with anemia, the nurse observes the patient's beefy red tongue. The nurse is aware that this is a sign of what kind of anemia? Iron deficiency Megaloblastic Autoimmune Folate deficiency
Megaloblastic A beefy, red, sore tongue is a characteristic indicator of megaloblastic anemia. The nurse should assess for other signs such as fatigue, hypotension, and tachycardia. Safety issues should also be assessed because balance, coordination, and gait are affected.
The nurse cares for an older adult client with unprovoked back pain and increased serum protein. Which hematologic neoplasm does the nurse suspect the client has? Multiple myeloma Non-Hodgkin lymphoma Chronic myeloid leukemia Hodgkin lymphoma
Multiple myeloma Any older adult with unprovoked or unexplained back pain and increased protein in the serum should be assessed for multiple myeloma. Bone pain occurs because of bone breakdown and the malignant cells of multiple myeloma increase the serum protein levels.
A client with acute myeloid leukemia has a fever. What pathophysiological process does the nurse recognize is the cause of the client's fever? Neutropenia Pancytopenia Anemia Thrombocytopenia
Neutropenia Fever and infection result from a decrease in neutrophils (neutropenia). Decreased red blood cells (anemia) cause weakness, fatigue, dyspnea on exertion, and pallor in AML. Pancytopenia, an overall decrease in all blood components, is not cause of fever in clients with AML. Decreased platelet count (thrombocytopenia) causes petechiae and bruising in AML.
The nurse is caring for a client with multiple myeloma. Why would it be important to assess this client for fractures? Osteolytic activating factor weakens bones producing fractures. Osteopathic tumors destroy bone causing fractures. Osteoclasts break down bone cells so pathologic fractures occur. Osteosarcomas form producing pathologic fractures.
Osteoclasts break down bone cells so pathologic fractures occur. The abnormal plasma cells proliferate in the bone marrow, where they release osteoclast-activating factor. This, in turn, causes osteoclasts to break down bone cells, resulting in increased blood calcium and pathologic fractures. The plasma cells also form single or multiple osteolytic (bone-destroying) tumors that produce a "punched-out" or "honeycombed" appearance in bones such as the spine, ribs, skull, pelvis, femurs, clavicles, and scapulae. Weakened vertebrae lead to compression of the spine accompanied by significant pain. The other options are distractors for this question.
A nurse is caring for a client with multiple myeloma. Which nursing intervention is most appropriate for this client? Balancing rest and activity Monitoring respiratory status Preventing bone injury Restricting fluid intake
Preventing bone injury When caring for a client with multiple myeloma, the nurse should focus on relieving pain, preventing bone injury and infection, and maintaining hydration. Monitoring respiratory status and balancing rest and activity are appropriate interventions for any client. To prevent such complications as pyelonephritis and renal calculi, the nurse should keep the client well hydrated — not restrict fluid intake.
A client with suspected multiple myeloma is reporting back pain. What is the priority nursing action? Have the client lie on a hard surface. Have the client rest. Send the client for a spinal x-ray study. Encourage ambulation.
Send the client for a spinal x-ray study. The client with myeloma can have bone pain, especially in the back and ribs. The pain will decrease with rest and increase with activity. Lying on a hard surface will not relieve the pain. The priority action is to make certain the client does not have a fractured spine, as the bone destruction in this disease is sufficiently severe to cause vertebral collapse.
A client is newly diagnosed with Hodgkin lymphoma. The nurse understands that the client's treatment will be based on what concept? Total blood cell count Involvement of lymph nodes Staging of disease Histology of tissue
Staging of disease Treatment of Hodgkin lymphoma is based on the stage of the disease, not the histology of tissue, involvement of lymph nodes, or total blood cell count.
A client with polycythemia vera reports gouty arthritis symptoms in the toes and fingers. What is the nurse's best understanding of the pathophysiological reason for this symptom? Excess red blood cells cause vascular injury in the joints. The dead red blood cells occlude the small vessels in the joints. Excess red blood cells produce extracellular toxins that build up. The dead red blood cells release excess uric acid.
The dead red blood cells release excess uric acid. There is a rapid proliferation of red blood cells from the marrow in polycythemia vera. However, these red blood cells die sooner than normal and the dead red blood cells release potassium and uric acid. This build up of uric acid in the blood leads to gouty arthritis symptoms.
The nurse is caring for a patient who will begin taking long-term biphosphate therapy. Why is it important for the nurse to encourage the patient to receive a thorough evaluation of dentition, including panoramic dental x-rays? The patient will develop gingival hyperplasia. The patient can develop loosening of the teeth. The patient is at risk for tooth decay. The patient can develop osteonecrosis of the jaw.
The patient can develop osteonecrosis of the jaw. Osteonecrosis of the jaw is an infrequent but serious complication that can arise in patients treated long-term with bisphosphonates; the mandible or maxilla are affected. Careful assessment for this complication should be conducted and a thorough evaluation of the patient's dentition should be performed prior to initiating bisphosphonate therapy, including panoramic dental x-rays.
One hour after the completion of a fresh frozen plasma transfusion, a client reports shortness of breath and is very anxious. The client's vital signs are BP 98/60, HR 110, temperature 99.4°F, and SaO2 88%. Auscultation of the lungs reveals posterior coarse crackles to the mid and lower lobes bilaterally. Based on the symptoms, the nurse suspects the client is experiencing which problem? Exacerbation of congestive heart failure Bacterial contamination of blood Transfusion-related acute lung injury Delayed hemolytic reaction
Transfusion-related acute lung injury Transfusion-related acute lung injury (TRALI) is a potentially fatal, idiosyncratic reaction that is defined as the development of acute lung injury within 6 hours after a blood transfusion. It is more likely to occur when plasma and platelets are transfused. Onset is abrupt (usually within 6 hours of transfusion, often within 2 hours). Signs and symptoms include acute shortness of breath, hypoxia (arterial oxygen saturation [SaO2] less than 90%; pressure of arterial oxygen [PaO2] to fraction of inspired oxygen [FIO2] ratio less than 300), hypotension, fever, and eventual pulmonary edema.
A nurse cares for a client with aplastic anemia. Which laboratory results will the nurse expect to find with this client? Select all that apply. Hemoglobin 7 g/dL Platelets 35,000 microliters Neutrophil count 17,000/microliter Neutrophil count 1200/microliter White blood cell count 10,000/microliter
Hemoglobin 7 g/dL Platelets 35,000 microliters Neutrophil count 1200/microliter Aplastic anemia causes pancytopenia, or overall decrease to all myeloid stem cell-derived cells. Pancytopenia manifests as neutrophil count less than 1500/microliter, hemoglobin less than 10 g/dL, and platelets less than 50,000/microliter.
A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms? Leukemia Hemolytic anemia Polycythemia vera Multiple myeloma
Multiple myeloma The first symptom usually is vague pain in the pelvis, spine, or ribs. As the disease progresses, the pain becomes more severe and localized. The pain intensifies with activity and is relieved by rest. When tumors replace bone marrow, pathologic fractures develop. Hemolytic anemia does not result in pathologic fractures nor does polycythemia vera or leukemia.
The nurse notes that a client with essential thrombocythemia has a headache and a platelet count of 1 million/mm3 (1 million/ ×109/L). Which additional neurologic findings will the nurse expect to assess in this client? Select all that apply. Paresthesias Transient ischemic attacks Diplopia Dizziness Facial paralysis
Paresthesias Transient ischemic attacks Diplopia Dizziness Essential thrombocythemia, also called primary thrombocythemia, is a rare, chronic, Philadelphia chromosome-negative myeloproliferative disorder characterized by an increased production of megakaryocytes. A marked increase in platelet production occurs. One of the most common neurologic symptoms of essential thrombocythemia is headaches. Other neurological manifestations that may be related to compromised blood flow include diplopia, dizziness, paresthesias, and transient ischemic attacks. Facial paralysis is not a symptom of essential thrombocytopenia.
The nurse is talking with the parents of a toddler who was diagnosed with hemophilia A. What instruction should the nurse give to the parents? Administer factor VIII intravenously at the first sign of bleeding Encourage the toddler to participate in playground activities with other toddlers Administer over-the-counter preparations for a cold Use nasal packing for any nose bleeds
Administer factor VIII intravenously at the first sign of bleeding Clients and families are taught to administer factor VIII intravenously. This helps to prevent bleeding episodes. Activities that minimize trauma are allowed for the toddler, however, playground activities may place the toddler at risk for increased bleeding. Over-the-counter cold preparations are to be avoided because they will interfere with platelet aggregation. Nasal packing is avoided because when the nasal packing is removed, bleeding may occur.
The nurse provides care for an older adult client, diagnosed with anemia, who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine the cause of the client's blood loss, which is the priority nursing action? Observe the client's stools for blood. Evaluate the client's dietary intake. Monitor the client's body temperature. Monitor the client's blood pressure.
Observe the client's stools for blood. If an older adult is anemic, blood loss from the gastrointestinal (GI) or genitourinary (GU) tracts is suspected. Observing the stool for blood will determine if the source of the client's bleeding is in the GI tract. Iron-deficiency anemia is unusual in older adults because the body does not eliminate excessive iron, thus increasing total body iron stores and necessitating maintenance of hydration. If evaluation of the GI and GU tracts does not reveal a source of bleeding, evaluating the client's diet may be appropriate; however, this is not the priority nursing action. Monitoring the client's body temperature and BP will assist the nurse in determining the source of the client's blood loss, but these are not priority nursing actions.
A client is diagnosed with primary myelofibrosis. Which assessment findings will the nurse expect to assess in this client? Select all that apply. Ruddy complexion Early satiety Abdominal discomfort Weight loss Bone pain
Weight loss Bone pain Abdominal discomfort Early satiety Primary myelofibrosis occurs as a result of neoplastic transformation of early hematopoietic stem cells. This disease is characterized by bone marrow fibrosis or scarring, extramedullary hematopoiesis (typically involving the spleen and/or liver), leukocytosis, thrombocytosis, elevated lactic dehydrogenase (LDH), and anemia. Symptoms associated with this condition include bone pain, weight loss, early satiety, and abdominal discomfort. A ruddy complexion is not associated with primary myelofibrosis.
A woman's routine complete blood count (CBC) revealed a highly elevated platelet level, and subsequent diagnostic testing has resulted in a diagnosis of primary thrombocythemia. The nurse has begun the relevant health education with the patient. What should the nurse teach this woman about her health problem? "Your doctor will likely order a series of blood transfusions for you over the next several months." "Primary thrombocythemia creates potential problems at both ends of the clotting spectrum: inappropriate clotting or inappropriate bleeding." "Primary thrombocythemia makes you quite vulnerable to hemorrhage, so you'll need regular injections of some important clotting factors." "It's very important that you try to adopt a diet that's high in organ meats and leafy green vegetables."
"Primary thrombocythemia creates potential problems at both ends of the clotting spectrum: inappropriate clotting or inappropriate bleeding." Primary thrombocythemia creates risks for significant thrombotic or hemorrhagic complications. Clotting factors and transfusions are not relevant treatments, and a high-iron diet is not necessary.
The charge nurse should intervene when observing a new nurse perform which action after a client has suffered a possible hemolytic blood transfusion reaction? Disposing of the blood container and tubing in biohazard waste. Informing the client to leave a urine sample after the client's next void. Notifying the blood bank of the reaction. Documenting the reaction in the client's medical record.
Disposing of the blood container and tubing in biohazard waste. The blood container and tubing should be returned to the blood bank for repeat typing and culture, and the blood bank should be notified of the reaction. A urine sample is collected as soon as possible to detect hemoglobin in the urine. Documenting the client's reaction in the medical record is an appropriate action.
A nurse cares for a client with severe hemoglobinuria after an upper respiratory infection and fever. Diagnostic testing reveals degraded hemoglobin within the client's erythrocytes. Which hematological condition does the nurse suspect the client has? Polycythemia vera Aplastic anemia Glucose-6-phosphate dehydrogenase deficiency Sickle cell disease
Glucose-6-phosphate dehydrogenase deficiency Glucose-6-phosphate dehydrogenase deficiency (G-6-PD) is the deficiency of a gene that produces an enzyme within the erythrocyte essential for membrane stability. Clients are asymptomatic and have normal hemoglobin levels and reticulocyte counts most of the time. However, after a normally-harmless virus or ingestion of a particular medication, clients develop pallor, jaundice, and hemoglobinuria (hemoglobin in the urine). The other answer choices are hematological diseases or conditions; however, these do not present in the same manner.
The nurse has been monitoring a patient's vital signs closely after initiating a transfusion of packed red blood cells (PRBCs). The nurse has observed that the patient's temperature is trending upward, and the patient is complaining of chills. The nurse has stopped the transfusion and informed the patient's health care provider, who believes that the patient is experiencing a febrile nonhemolytic transfusion reaction (FNHTR). What course of action should the nurse anticipate? Administering a bolus of normal saline Monitoring the patient closely and administering antipyretics Initiating apheresis and administering IV antihistamines Performing a stat cross-match and beginning a transfusion of the correct blood type
Monitoring the patient closely and administering antipyretics Although an FNHTR is not life-threatening, the fever, and particularly the chills and muscle stiffness, can be frightening to the patient and may be treated with antipyretics. An FNHTR does not necessitate apheresis or an infusion of IV fluids. The reaction does not denote that an incompatible blood type has been transfused.
