Chapter 32: Assessment of Hematologic Function and Treatment Modalities

14. The nurse educating a patient with anemia is describing the process of RBC production. When the patients kidneys sense a low level of oxygen in circulating blood, what physiologic response is initiated? 1. A) Increased stem cell synthesis 2. B) Decreased respiratory rate 3. C) Arterial vasoconstriction 4. D) Increased production of erythropoietin

D Feedback: If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (i.e., anemia), erythropoietin levels increase. The body does not compensate with vasoconstriction, decreased respiration, or increased stem cell activity.

5. A nurse is caring for a patient who undergoing preliminary testing for a hematologic disorder. What sign or symptom most likely suggests a potential hematologic disorder? A) Sudden change in level of consciousness (LOC) B) Recurrent infections C) Anaphylaxis D) Severe fatigue

D Feedback: The most common indicator of hematologic disease is extreme fatigue. This is more common than changes in LOC, infections, or anaphylaxis.

31. Two units of PRBCs have been ordered for a patient who has experienced a GI bleed. The patient is highly reluctant to receive a transfusion, stating, Im terrified of getting AIDS from a blood transfusion. How can the nurse best address the patients concerns? A) All the donated blood in the United States is treated with antiretroviral medications before it is used. B) That did happen in some high-profile cases in the twentieth century, but it is no longer a possibility. C) HIV was eradicated from the US blood supply in the early 2000s. D) The chances of contracting AIDS from a blood transfusion in the United States are exceedingly low.

D Feedback: The patient can be reassured about the very low possibility of contracting HIV from the transfusion. However, it is not an absolute impossibility. Antiretroviral medications are not introduced into donated blood. The blood supply is constantly dynamic, due to the brief life of donated blood.

28. A nurse at a blood donation clinic has completed the collection of blood from a woman. The woman states that she feels lightheaded and she appears visibly pale. What is the nurses most appropriate action? A) Help her into a sitting position with her head lowered below her knees. B) Administer supplementary oxygen by nasal prongs. C) Obtain a full set of vital signs. D) Inform a physician or other primary care provider.

A Feedback: A donor who appears pale or complains of faintness should immediately lie down or sit with the head lowered below the knees. He or she should be observed for another 30 minutes. There is no immediate need for a physicians care. Supplementary oxygen may be beneficial, but may take too much time to facilitate before a syncopal episode. Repositioning must precede assessment of vital signs.

12. A patient has been diagnosed with a lymphoid stem cell defect. This patient has the potential for a problem involving which of the following? 1. A) Plasma cells 2. B) Neutrophils 3. C) Red blood cells 4. D) Platelets

Ans: A Feedback: A defect in a myeloid stem cell can cause problems with erythrocyte, leukocyte, and platelet production. In contrast, a defect in the lymphoid stem cell can cause problems with T or B lymphocytes, plasma cells (a more differentiated form of B lymphocyte), or natural killer (NK) cells.

19. A patients most recent blood work reveals low levels of albumin. This assessment finding should suggest the possibility of what nursing diagnosis? 1. A) Risk for imbalanced fluid volume related to low albumin 2. B) Risk for infection related to low albumin 3. C) Ineffective tissue perfusion related to low albumin 4. D) Impaired skin integrity related to low albumin

Ans: A Feedback: Albumin is particularly important for the maintenance of fluid balance within the vascular system. Deficiencies nearly always manifest as fluid imbalances. Tissue oxygenation and skin integrity are not normally affected. Low albumin does not constitute a risk for infection.

15. An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate? 1. A) Stool for occult blood 2. B) Bone marrow biopsy 3. C) Lumbar puncture 4. D) Urinalysis

Ans: A Feedback: Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow). Bleeding in the GI tract can be preliminarily identified by testing stool for the presence of blood. A bone marrow biopsy would not be undertaken for the sole purpose of investigating an iron deficiency. Lumbar puncture and urinalysis would not be clinically relevant.

26. The nurses brief review of a patients electronic health record indicates that the patient regularly undergoes therapeutic phlebotomy. Which of the following rationales for this procedure is most plausible? 1. A) The patient may chronically produce excess red blood cells. 2. B) The patient may frequently experience a low relative plasma volume. 3. C) The patient may have impaired stem cell function. 4. D) The patient may previously have undergone bone marrow biopsy.

Ans: A Feedback: Persistently elevated hematocrit is an indication for therapeutic phlebotomy. It is not used to address excess or deficient plasma volume and is not related to stem cell function. Bone marrow biopsy is not an indication for therapeutic phlebotomy.

2. A man suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What occurs in primary hemostasis? 1. A) Severed blood vessels constrict. 2. B) Thromboplastin is released. 3. C) Prothrombin is converted to thrombin. 4. D) Fibrin is lysed.

Ans: A Feedback: Primary hemostasis involves the severed vessel constricting and platelets collecting at the injury site. Secondary hemostasis occurs when thromboplastin is released, prothrombin converts to thrombin, and fibrin is lysed.

38. The nurse is preparing to administer a unit of platelets to an adult patient. When administering this blood product, which of the following actions should the nurse perform? 1. A) Administer the platelets as rapidly as the patient can tolerate. 2. B) Establish IV access as soon as the platelets arrive from the blood bank. 3. C) Ensure that the patient has a patent central venous catheter. 4. D) Aspirate 10 to 15 mL of blood from the patients IV immediately following the transfusion.

Ans: A Feedback: The nurse should infuse each unit of platelets as fast as patient can tolerate to diminish platelet clumping during administration. IV access should be established prior to obtaining the platelets from the blood bank. A central line is appropriate for administration, but peripheral IV access (22-gauge or larger) is sufficient. There is no need to aspirate after the transfusion.

34. A patient is receiving a blood transfusion and complains of a new onset of slight dyspnea. The nurses rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurses most appropriate action? 1. A) Slow the infusion rate and monitor the patient closely. 2. B) Discontinue the transfusion and begin resuscitation. 3. C) Pause the transfusion and administer a 250 mL bolus of normal saline. 4. D) Discontinue the transfusion and administer a beta-blocker, as ordered.

Ans: A Feedback: The patient is showing early signs of hypervolemia; the nurse should slow the infusion rate and assess the patient closely for any signs of exacerbation. At this stage, discontinuing the transfusion is not necessary. A bolus would worsen the patients fluid overload.

9. Through the process of hematopoiesis, stem cells differentiate into either myeloid or lymphoid stem cells. Into what do myeloid stem cells further differentiate? Select all that apply. 1. A) Leukocytes 2. B) Natural killer cells 3. C) Cytokines 4. D) Platelets 5. E) Erythrocytes

Ans: A, D, E Feedback: Myeloid stem cells differentiate into three broad cell types: erythrocytes, leukocytes, and platelets. Natural killer cells and cytokines do not originate as myeloid stem cells.

40. A patients electronic health record states that the patient receives regular transfusions of factor IX. The nurse would be justified in suspecting that this patient has what diagnosis? 1. A) Leukemia 2. B) Hemophilia 3. C) Hypoproliferative anemia 4. D) Hodgkins lymphoma

Ans: B Feedback: Administration of clotting factors is used to treat diseases where these factors are absent or insufficient; hemophilia is among the most common of these diseases. Factor IX is not used in the treatment of leukemia, lymphoma, or anemia.

25. A patient is scheduled for a splenectomy. During discharge education, what teaching point should the nurse prioritize? 1. A) The importance of adhering to prescribed immunosuppressant therapy 2. B) The need to report any signs or symptoms of infection promptly 3. C) The need to ensure adequate folic acid, iron, and vitamin B12 intake 4. D) The importance of limiting activity postoperatively to prevent hemorrhage

Ans: B Feedback: After splenectomy, the patient is instructed to seek prompt medical attention if even relatively minor symptoms of infection occur. Often, patients with high platelet counts have even higher counts after splenectomy, which can predispose them to serious thrombotic or hemorrhagic problems. However, this increase is usually transient and therefore often does not warrant additional treatment. Dietary modifications are not normally necessary and immunosuppressants would be strongly contraindicated.

32. A patient is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this patients adverse reaction? 1. A) Antibodies to donor leukocytes remained in the blood. 2. B) The donor blood was incompatible with that of the patient. 3. C) The patient had a sensitivity reaction to a plasma protein in the blood. 4. D) The blood was infused too quickly and overwhelmed the patients circulatory system.

Ans: B Feedback: An acute hemolytic reaction occurs when the donor blood is incompatible with that of the recipient. In the case of a febrile nonhemolytic reaction, antibodies to donor leukocytes remain in the unit of blood or blood component. An allergic reaction is a sensitivity reaction to a plasma protein within the blood component. Hypervolemia does not cause an acute hemolytic reaction.

A patient on the medical unit is receiving a unit of PRBCs. Difficult IV access has necessitated a slow infusion rate and the nurse notes that the infusion began 4 hours ago. What is the nurses most appropriate action? A) Apply an icepack to the blood that remains to be infused. B) Discontinue the remainder of the PRBC transfusion and inform the physician. C) Disconnect the bag of PRBCs, cool for 30 minutes and then administer. D) Administer the remaining PRBCs by the IV direct (IV push) route.

Ans: B Feedback: Because of the risk of infection, a PRBC transfusion should not exceed 4 hours. Remaining blood should not be transfused, even if it is cooled. Blood is not administered by the IV direct route.

16. A patient is being treated for the effects of a longstanding vitamin B12 deficiency. What aspect of the patients health history would most likely predispose her to this deficiency? 1. A) The patient has irregular menstrual periods. 2. B) The patient is a vegan. 3. C) The patient donated blood 60 days ago. 4. D) The patient frequently smokes marijuana.

Ans: B Feedback: Because vitamin B12 is found only in foods of animal origin, strict vegetarians may ingest little vitamin B12. Irregular menstrual periods, marijuana use, and blood donation would not precipitate a vitamin B12 deficiency.

21. The nurse is providing care for an older adult who has a hematologic disorder. What age-related change in hematologic function should the nurse integrate into care planning? 1. A) Bone marrow in older adults produces a smaller proportion of healthy, functional blood cells. 2. B) Older adults are less able to increase blood cell production when demand suddenly increases. 3. C) Stem cells in older adults eventually lose their ability to differentiate. 4. D) The ratio of plasma to erythrocytes and lymphocytes increases with age.

Ans: B Feedback: Due to a variety of factors, when an older person needs more blood cells, the bone marrow may not be able to increase production of these cells adequately. Stem cell activity continues throughout the lifespan, although at a somewhat decreased rate. The proportion of functional cells does not greatly decrease and the relative volume of plasma does not change significantly.

20. An individual has accidentally cut his hand, immediately initiating the process of hemostasis. Following vasoconstriction, what event in the process of hemostasis will take place? 1. A) Fibrin will be activated at the bleeding site. 2. B) Platelets will aggregate at the injury site. 3. C) Thromboplastin will form a clot. 4. D) Prothrombin will be converted to thrombin.

Ans: B Feedback: Following vasoconstriction, circulating platelets aggregate at the site and adhere to the vessel and to one another, forming an unstable hemostatic plug. Events involved in the clotting cascade take place subsequent to this initial platelet action.

27. A nurse has participated in organizing a blood donation drive at a local community center. Which of the following individuals would most likely be disallowed from donating blood? 1. A) A man who is 81 years of age 2. B) A woman whose blood pressure is 88/51 mm Hg 3. C) A man who donated blood 4 months ago 4. D) A woman who has type 1 diabetes

Ans: B Feedback: For potential blood donors, systolic arterial BP should be 90 to 180 mm Hg, and the diastolic pressure should be 50 to 100 mm Hg. There is no absolute upper age limit. Donation 4 months ago does not preclude safe repeat donation and diabetes is not a contraindication.

22. A clients health history reveals daily consumption of two to three bottles of wine. The nurse should plan assessments and interventions in light of the patients increased risk for what hematologic disorder? 1. A) Leukemia 2. B) Anemia 3. C) Thrombocytopenia 4. D) Lymphoma

Ans: B Feedback: Heavy alcohol use is associated with numerous health problems, including anemia. Leukemia and lymphoma are not associated with alcohol use; RBC levels are typically affected more than platelet levels.

13. The nurse is describing normal RBC physiology to a patient who has a diagnosis of anemia. The nurse should explain that the RBCs consist primarily of which of the following? 1. A) Plasminogen 2. B) Hemoglobin 3. C) Hematocrit 4. D) Fibrin

Ans: B Feedback: Mature erythrocytes consist primarily of hemoglobin, which contains iron and makes up 95% of the cell mass. RBCs are not made of fibrin or plasminogen. Hematocrit is a measure of RBC volume in whole blood.

The nurse is describing the role of plasminogen in the clotting cascade. Where in the body is plasminogen present? A) Myocardial muscle tissue B) All body fluids C) Cerebral tissue D) Venous and arterial vessel walls

Ans: B Feedback: Plasminogen, which is present in all body fluids, circulates with fibrinogen. Plasminogen is found in body fluids, not tissue.

36. A patient is receiving the first of two ordered units of PRBCs. Shortly after the initiation of the transfusion, the patient complains of chills and experiences a sharp increase in temperature. What is the nurses priority action? 1. A) Position the patient in high Fowlers. 2. B) Discontinue the transfusion. 3. C) Auscultate the patients lungs. 4. D) Obtain a blood specimen from the patient.

Ans: B Feedback: Stopping the transfusion is the first step in any suspected transfusion reaction. This must precede other assessments and interventions, including repositioning, chest auscultation, and collecting specimens.

11. A patient undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions? 1. A) Safe transfusion for patients with a history of transfusion reactions 2. B) Prevention of viral infections from another persons blood 3. C) Avoidance of complications in patients with alloantibodies 4. D) Prevention of alloimmunization

Ans: B Feedback: The primary advantage of autologous transfusions is the prevention of viral infections from another persons blood. Other secondary advantages include safe transfusion for patients with a history of transfusion reactions, prevention of alloimmunization, and avoidance of complications in patients with alloantibodies. 12. A patient has been diagnosed with a lymphoid stem cell defect. This patient has the potential for a problem involving which of the following?

39. Which of the following circumstances would most clearly warrant autologous blood donation? 1. A) The patient has type-O blood. 2. B) The patient has sickle cell disease or a thalassemia. 3. C) The patient has elective surgery pending. 4. D) The patient has hepatitis C.

Ans: C Feedback: Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high. Type-O blood, hepatitis, sickle cell disease, and thalassemia are not clear indications for autologous donation.

1. A patient with a hematologic disorder asks the nurse how the body forms blood cells. The nurse should describe a process that takes place where? 1. A) In the spleen 2. B) In the kidneys 3. C) In the bone marrow 4. D) In the liver

Ans: C Feedback: Bone marrow is the primary site for hematopoiesis. The liver and spleen may be involved during embryonic development or when marrow is destroyed. The kidneys release erythropoietin, which stimulates the marrow to increase production of red blood cells (RBCs). However, blood cells are not primarily formed in the spleen, kidneys, or liver.

37. Fresh-frozen plasma (FFP) has been ordered for a hospital patient. Prior to administration of this blood product, the nurse should prioritize what patient education? 1. A) Infection risks associated with FFP administration 2. B) Physiologic functions of plasma 3. C) Signs and symptoms of a transfusion reaction 4. D) Strategies for managing transfusion-associated anxiety

Ans: C Feedback: Patients should be educated about signs and symptoms of transfusion reactions prior to administration of any blood product. In most cases, this is priority over education relating to infection. Anxiety may be an issue for some patients, but transfusion reactions are a possibility for all patients. Teaching about the functions of plasma is not likely a high priority.

24. A patient has been scheduled for a bone marrow biopsy and admits to the nurse that she is worried about the pain involved with the procedure. What patient education is most accurate? 1. A) Youll be given painkillers before the test, so there wont likely be any pain? 2. B) Youll feel some pain when the needle enters your skin, but none when the needle enters the bone because of the absence of nerves in bone. 3. C) Most people feel some brief, sharp pain when the needle enters the bone. 4. D) Ill be there with you, and Ill try to help you keep your mind off the pain.

Ans: C Feedback: Patients typically feel a pressure sensation as the needle is advanced into position. The actual aspiration always causes sharp, but brief pain, resulting from the suction exerted as the marrow is aspirated into the syringe; the patient should be warned about this. Stating, Ill try to help you keep your mind off the pain may increase the patients fears of pain, because this does not help the patient know what to expect.

3. A patient has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the patients consequent increase in RBC production, the nurse knows that the patient may need to increase her daily intake of what substance? 1. A) Vitamin E 2. B) Vitamin D 3. C) Iron 4. D) Magnesium

Ans: C Feedback: To replace blood loss, the rate of red cell production increases. Iron is incorporated into hemoglobin. Vitamins E and D and magnesium do not need to be increased when RBC production is increased.

8. The nurse is caring for a patient who has developed scar tissue in many of the areas that normally produce blood cells. What organs can become active in blood cell production by the process of extramedullary hematopoiesis? 1. A) Spleen and kidneys 2. B) Kidneys and pancreas 3. C) Pancreas and liver 4. D) Liver and spleen

Ans: D Feedback: In adults with disease that causes marrow destruction, fibrosis, or scarring, the liver and spleen can also resume production of blood cells by a process known as extramedullary hematopoiesis. The kidneys and pancreas do not produce blood cells for the body.

35. A patient lives with a diagnosis of sickle cell anemia and receives frequent blood transfusions. The nurse should recognize the patients consequent risk of what complication of treatment? 1. A) Hypovolemia 2. B) Vitamin B12 deficiency 3. C) Thrombocytopenia 4. D) Iron overload

Ans: D Feedback: Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. These individuals are not at risk for hypovolemia and there is no consequent risk for low platelet or vitamin B12 levels.

23. A patients diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin (Coumadin), an anticoagulant. When assessing the therapeutic response to this medication, what is the nurses most appropriate action? 1. A) Assess for signs of myelosuppression. 2. B) Review the patients platelet level. 3. C) Assess the patients capillary refill time. 4. D) Review the patients international normalized ratio (INR).

Ans: D Feedback: The INR and aPTT serve as useful screening tools for evaluating a patients clotting ability and to monitor the therapeutic effectiveness of anticoagulant medications. The patients platelet level is not normally used as a short-term indicator of anticoagulation effectiveness. Assessing the patient for signs of myelosuppression and capillary refill time does not address the effectiveness of anticoagulants.

33. An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction? 1. A) Ensure that blood components are never infused at a rate greater than 125 mL/hr. 2. B) Administer prophylactic antihistamines prior to all blood transfusions. 3. C) Establish baseline vital signs for all patients receiving transfusions. 4. D) Be vigilant in identifying the patient and the blood component.

Ans: D Feedback: The most common causes of acute hemolytic reaction are errors in blood component labeling and patient identification that result in the administration of an ABO-incompatible transfusion. Actions to address these causes are necessary in all health care settings. Prophylactic antihistamines are not normally administered, and would not prevent acute hemolytic reactions. Similarly, baseline vital signs and slow administration will not prevent this reaction.

10. A patients wound has begun to heal and the blood clot which formed is no longer necessary. When a blood clot is no longer needed, the fibrinogen and fibrin will be digested by which of the following? 1. A) Plasminogen 2. B) Thrombin 3. C) Prothrombin 4. D) Plasmin

Ans: D Feedback: The substance plasminogen is required to lyse (break down) the fibrin. Plasminogen, which is present in all body fluids, circulates with fibrinogen and is therefore incorporated into the fibrin clot as it forms. When the clot is no longer needed (e.g., after an injured blood vessel has healed), the plasminogen is activated to form plasmin. Plasmin digests the fibrinogen and fibrin. Prothrombin is converted to thrombin, which in turn catalyzes the conversion of fibrinogen to fibrin so a clot can form.

4. The nurse is planning the care of a patient with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this patients health problem is due to what? 1. A) Production of inadequate quantities of RBCs 2. B) Premature release of immature RBCs 3. C) Injury to the RBCs in circulation 4. D) Abnormalities in the structure and function RBCs

Ans: D Feedback: Vitamin B12 and folic acid deficiencies are characterized by the production of abnormally large erythrocytes called megaloblasts. Because these cells are abnormal, many are sequestered (trapped) while still in the bone marrow, and their rate of release is decreased. Some of these cells actually die in the marrow before they can be released into the circulation. This results in megaloblastic anemia. This pathologic process does not involve inadequate production, premature release, or injury to existing RBCs.

18. A nurse is educating a patient about the role of B lymphocytes. The nurses description will include which of the following physiologic processes? 1. A) Stem cell differentiation 2. B) Cytokine production 3. C) Phagocytosis 4. D) Antibody production

Ans: D Prior to the nurse assessing the patients BP, the patient should try to rest quietly for 5 minutes. The forearm should be positioned at heart level. Caffeine products and cigarette smoking should be avoided for at least 30 minutes prior to the visit. Recent fluid intake is not normally relevant.

The nurse caring for a patient receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the patient is having difficulty breathing and complains of severe chest tightness. What is the most appropriate initial action for the nurse to take? A) Notify the patients physician. B) Stop the transfusion immediately. C) Remove the patients IV access. D) Assess the patients chest sounds and vital signs.

B Feedback: Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the patients vital signs, and notify the physician. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The patients IV access should not be removed.

17. The nurses review of a patients most recent blood work reveals a significant increase in the number of band cells. The nurses subsequent assessment should focus on which of the following? A) Respiratory function B) Evidence of decreased tissue perfusion C) Signs and symptoms of infection D) Recent changes in activity tolerance

C Feedback: Ordinarily, band cells account for only a small percentage of circulating granulocytes, although their percentage can increase greatly under conditions in which neutrophil production increases, such as infection. This finding is not suggestive of problems with oxygenation and subsequent activity intolerance.

A patients low hemoglobin level has necessitated transfusion of PRBCs. Prior to administration, what action should the nurse perform? A) Have the patient identify his or her blood type in writing. B) Ensure that the patient has granted verbal consent for transfusion. C) Assess the patients vital signs to establish baselines. D) Facilitate insertion of a central venous catheter.

C Feedback: Prior to a transfusion, the nurse must take the patients temperature, pulse, respiration, and BP to establish a baseline. Written consent is required and the patients blood type is determined by type and cross match, not by the patients self-declaration. Peripheral venous access is sufficient for blood transfusion.