Davis 27 & 28

A patient reports fatigue and lack of ability to concentrate. The physical examination is unremarkable; laboratory results show a hemoglobin of 11 g/dL and a hematocrit of 37%. Which other laboratory finding would suggest iron deficiency? 1. Low serum ferritin levels 2. Higher than normal hemoglobin level 3. Elevated erythrocyte sedimentation rate 4. Lower than normal blood-urea-nitrogen level

1 Hemoglobin and hematocrit levels are below normal in anemia. Serum iron, ferritin, and total iron-binding capacity measurements are done to diagnose iron-deficiency anemia.

The nurse enters the room of a patient an hour after initiating a blood transfusion and notes that the patient is trembling, reports feeling cold, and has a temperature of 100.3°F. Which reaction is most likely occurring in this patient? 1. Febrile reaction 2. Urticarial reaction 3. Hemolytic reaction 4. Anaphylactic reaction

1 The most common reaction to a blood transfusion is a febrile reaction, which has symptoms of increasing fever and shaking chills. This reaction occurs in up to 2% of people, and the risk increases with each unit of blood product given to the patient. Urticarial reactions are considered to be minor allergic reactions; the cardinal sign is the appearance of a hive-like rash. Hemolytic reactions are the most deadly and generally occur within minutes of starting the transfusion; symptoms include back pain, chest pain, chills, fever, shortness of breath, nausea, and vomiting. An anaphylactic reaction results in respiratory or cardiovascular collapse and occurs almost immediately upon initiating the transfusion.

The nurse notes that a patient has a low red blood cell count. Which factors influence the production of red blood cells? Select all that apply. 1. Blood oxygen level 2. Dietary intake of iron 3. Dietary intake of protein 4. Dietary intake of folic acid 5. Blood carbon dioxide level 6. Dietary intake of intrinsic factor

1,2,3,4 The rate of red blood cell production is most influenced by the level of oxygen in the blood, but sufficient dietary intake of protein, iron, and folic acid are required to synthesize the hemoglobin the red blood cells carry. Intrinsic factor is produced by the small intestine and does not come from a dietary source. Blood carbon dioxide levels do not determine red blood cell production.

The nurse is providing care for a patient with anemia. What should the nurse encourage the patient to include in the diet? Select all that apply. 1. Milk 2. Steak 3. Beans 4. Oysters 5. Carrots 6. Orange juice

1,2,3,4,6 Sufficient dietary intake of protein and iron to synthesize hemoglobin is also required for normal production of red blood cells. Folic acid and vitamin B12 are necessary for DNA synthesis in the stem cells of the red bone marrow. Oysters and beef are excellent sources of iron. Beans are a good source of protein. Orange juice is a good source of folic acid. Milk is a good source of vitamin B12. Carrots are a healthy food choice but do not provide essential nutrients required for red blood cell production.

A patient is being admitted for treatment of anemia. What manifestations should the nurse expect to assess in this patient? Select all that apply. 1. Fatigue 2. Anorexia 3. Flank pain 4. Peripheral edema 5. Shortness of breath

1,5 Anemia results in symptoms such as shortness of breath and fatigue. Anorexia is not specifically identified as a manifestation of anemia. Flank pain could indicate a renal disorder. Peripheral edema could be due to fluid imbalance or a respiratory or cardiac disorder.

The results of laboratory testing performed to determine a patient's coagulation status are elevated. What should the nurse suspect is occuring with the patient who is not receiving any anticoagulant therapy? 1. Spleen damage 2. Liver malfunction 3. Red blood cell destruction 4. White bone marrow damage

2 Abnormalities in these values when the patient is not receiving anticoagulant therapy can indicate liver malfunction and bleeding tendency. Alterations in coagulation are not manifestations of spleen damage, red blood cell destruction, or white bone marrow damage.

A patient is diagnosed with several edematous lymph nodes. What should the nurse explain to the patient about the purpose of lymph nodes in the body? Select all that apply. 1. Lymph nodes maintain blood pressure. 2. Lymph nodes phagocytize foreign material. 3. Lymph nodes house activated lymphocytes and macrophages. 4. Lymph nodes faciltate the transportation of oxygen to body tissues. 5. Lymph nodes remove pathogens before returning lymph to the blood.

2,3,5 Lymph nodes are masses of lymphatic tissue along the pathways of the lymph vessels. They house activated lymphocytes and macrophages. Nodes are scattered throughout the body and remove pathogens before the lymph is returned to the blood. Foreign materials are phagocytized by fixed macrophages; lymphocytes form immune responses. Lymph nodes do not maintain blood pressure or facilitate the transportation of oxygen to body tissues.

While working on a surgical unit, the nurse is notified of a critical laboratory value for a patient whose hemoglobin is 7.4 g/dL. Which is most important for the nurse to collect from the patient? 1. Skin color 2. Blood pressure 3. Respiratory rate 4. Intake and output

3 Because hemoglobin carries oxygen, a patient with a low hemoglobin may be short of breath and tachypneic. Blood pressure, skin color, and intake and output may be important, but they are secondary to oxygenation.

The nurse is caring for a patient with sickle cell anemia who is experiencing iron build-up caused by repeated blood transfusions. Which medication should the nurse expect to be prescribed for this patient's health problem? 1. Hydrodiuril 2. Corticosteroids 3. Deferasirox(Exjade) 4. Hydroxyurea (Droxia)

3 Frequent blood transfusions in the care of the patient with sickle cell anemia can cause high levels of iron to build up in the body. Deferasirox (Exjade) is a medication that may be given to decrease the excess iron levels. Corticosteroids may reduce the need for analgesics and oxygen. Hydroxyurea (Droxia) is a drug that has been shown to decrease crises, but it can cause life-threatening side effects. Hydrodiuril is a diuretic which is not used in the treatment of a patient with sickle cell anemia.

The nurse is reviewing manifestations of anemia. Numbness of the hands or feet, a red beefy tongue, shortness of breath, and fatigue would be assessed in the patient with which type of anemia? 1. Thalassemia 2. Aplastic anemia 3. Pernicious anemia 4. Sickle-cell anemia

3 In addition to symptoms of shortness of breath, fatigue, pallor, and tachypnea, which are general characteristics of anemia, pernicious anemia is often characterized by a red beefy tongue and numbness of the hands or feet due to lack of vitamin B12. Symptoms of thalassemia include shortness of breath, fatigue, pallor, and tachypnea. Symptoms of aplastic anemia include tachycardia, heart failure, ecchymoses and petechiae. Common symptoms produced during sickle cell crises include severe pain and swelling in the joints, abdominal pain, hypoxia, and fever.

The nurse is assessing a patient with sickle cell anemia and notes that his fingers and toes are significantly different lengths. Which information about this finding should the nurse use to guide further assessment and care of this patient? 1. The patient has been overexerting with exercise 2. The patient is at risk for a crisis in the next week. 3. The patient has likely had many repeat sickle cell crises. 4. The patient may be overmedicating with analgesics during crises.

3 In sickle cell crises, sickled cells impede circulation, causing pain and swelling in the joints, which can lead to uneven growth of fingers and toes from repeated infarctions of the small bones in the hand and foot. The uneven growths of the fingers and toes does not indicate that the patient has been over-exercising, is going to have a crisis within the next week, or is being overmedicated during a crisis.

A 17-year-old patient is seen because of a severe sore throat and a temperature of 101.5°F. On examination, the nurse finds a red, inflamed tonsil and slightly swollen cervical lymph nodes. Results of the complete blood count reveal elevated segmented neutrophils, elevated bands, and decreased lymphocytes. Which type of infection is the patient most likely experiencing? 1. Viral 2. Fungal 3. Bacterial 4. Parasitic

3 A rise in segmented (mature) neutrophils and bands (immature neutrophils) indicates a bacterial infection that is worsening. If the segmented neutrophils are elevated but the bands are in normal range, it is probably a new bacterial infection. A drop in semented neutrophils, bands, and elevated lymphocytes are associated with viral infections. There are no particular complete blood count changes associated with fungal infections. Eosinophils respond to parasitic infections.

An antiglobulin test is being performed on a patient's blood sample. When the results are placed in the medical record, the nurse should look for which diagnostic test? 1. Coombs' test 2. ABO typing 3. RH typing 4. Crossmatching

1 The direct antiglobulin is also known as the Coombs' test. This test along with ABO typing, RH typing, and crossmatching blood samples are all agglutination tests.

A patient with chronic obstructive pulmonary disease (COPD) has developed secondary polycythemia. Which observations by the home health nurse indicate that the patient is correctly following instructions to reduce complications of polycythemia? Select all that apply. 1. The patient keeps the legs elevated. 2. The patient is wearing support hose. 3. The patient eats frequent small meals each day. 4. The patient reports taking anticoagulants as ordered. 5. The patient avoids unnecessary movement or exercise. 6. The nurse observes water near the patient and a record of intake.

1,2,3,4,5 A patient with secondary polycythemia should remain active if possible or if bedrest is needed, should perform active range-of-motion exercises. The use of support hose and elevating the legs when seated is encouraged as is intake of at least 3 L of water daily. Frequent small meals are better tolerated when liver involvement is present. Anticoagulant therapy may be provided to help prevent thrombosis.

The home health nurse is visiting a patient who was treated for idiopathic thrombocytopenic purpura and released with instructions about how to prevent bleeding. Which observations by the nurse indicate that the patient needs further teaching? Select all that apply. 1. The house is cluttered. 2. The patient is observed repeatedly blowing his nose. 3. The patient reports constipation and straining at stool. 4. The patient is wearing shoes while walking around the house. 5. The nurse notices a safety razor and dental floss on the bathroom sink. 6. The patient keeps a journal of all medications taken and tells the nurse that aspirin and NSAIDS are on the "Do Not Use" list.

1,2,3,5 To decrease the chance of bleeding, the patient should use an electric razor, not a safety razor; avoid flossing; and use a soft toothbrush. The house should be clutter free to reduce the risk of falling and bumping into things, causing bruising. The patient should use a stool softener and diet so that straining is not necessary. The patient should be instructed to avoid blowing his nose. Wearing shoes or slippers while walking in the house and not using aspirin or NSAIDS indicate following instructions.

A patient is scheduled for tests to determine the cause for a low red blood cell count. On which purposes should the nurse focus when identifying the types of tests this patient will have performed? Select all that apply. 1. Massive blood loss 2. Chronic blood loss 3. Fulminating systemic infection 4. Impaired production of red blood cells 5. Increased destruction of red blood cells

1,2,4,5 A decrease in the number of red blood cells can be caused by impaired production of red blood cells, increased destruction of red blood cells, or massive or chronic blood loss. A fulminating systemic infection would impact the number of white blood cells.

A patient is diagnosed with secondary polycythemia vera. On which body systems should the nurse focus when collecting data on this patient? Select all that apply. 1. Respiratory 2. Neurological 3. Genitourinary 4. Cardiovascular 5. Musculoskeletal

1,4 Secondary polycythemia is the result of long-term hypoxia. Common coexisting conditions that may predispose a patient to secondary polycythemia include pulmonary diseases, such as COPD, and cardiovascular problems such as chronic heart failure. The nurse should focus on the patient's respiratory and cardiovascular systems. Seconday polycythemia does not affect the neurological, genitourinary, or musculoskeletal systems.

During the physical assessment of a patient, the nurse notes cyanosis and course dry skin. Which hematologic problems should the nurse suspect this patient is experiencing? Select all that apply. 1. Anemia 2. Infection 3. Hemolysis 4. Allegic response5. Po or oxygenation

1,5 Coarse dry skin is associated with some anemias. Cyanosis is associated with poor oxygenation. Reddened skin is associated with an infection. Jaundice is associated with hemolysis. Itching is associated with an allergic response.

A patient is prescribed to receive 4 units of packed red blood cells. Which health problem is this patient most likely experiencing? 1. Hypovolemia 2. Acute blood loss 3. Thrombocytopenia 4. Insufficient clotting factors

2 Packed red blood cells are most often prescribed for anemia or acute bleeding. Albumin is prescribed for hypovolemia caused by hypoalbuminemia. Platelets are used for thrombocytopenia. Fresh frozen plasma is used to replace insufficient clotting factors.

The nurse is reviewing laboratory values for a patient with a bleeding disorder. Which factors should the nurse realize prevent excess clotting in the vascular system? Select all that apply. 1. Fibrin 2. Heparin 3. Serotonin 4. Prothrombin 5. Antithrombin 6. Platelet factors

2,5 Excessive clotting in blood vessels is prevented by heparin produced by mast cells, by antithrombin synthesized in the liver, and by the endothelial lining of the blood vessels, which repels platelets. Platelets release serotonin, which promotes vasoconstriction. Prothrombin and fibrin are factors involved in the clotting process.

The nurse is collecting interview data on a clinic patient who had cardiopulmonary bypass surgery 6 months ago. The patient reports symptoms of fatigue. On physical examination, the nurse notices petechiae and large, blue-black, bruise-like spots on the patient's arms and legs. In addition to a complete blood count and clotting studies, which diagnostic test should the nurse expect to be ordered to aid in diagnosis? 1. Electrolyte studies 2. Liver function tests 3. Bone marrow biopsy 4. Renal function studies

3 Ecchymoses and petechiae are signs of aplastic anemia, a type of anemia that sometimes occurs after use of cardiopulmonary bypass. In aplastic anemia, the bone marrow becomes incapable of producing blood cells, resulting in pancytopenia, or reduced numbers of all formed elements in the blood, including red blood cells, white blood cells, and platelets. The ecchymoses and petechiae indicate hemorrhaging due to reduced number of platelets. As with other forms of anemia, lack of red blood cells leads to symptoms of weakness, pallor, fatigue, and shortness of breath. The lack of white blood cells increases the risk of infection. A bone marrow biopsy, revealing a "dry tap," in which the bone marrow extracted is pale, fatty, yellow, and fibrous (instead of red and gelatinous), can confirm the diagnosis. Whether congenital or caused by exposure to toxic chemicals, chemotherapy, or cardiopulmonary bypass, aplastic anemia is a serious condition that must be treated aggressively to reduce blood loss and prevent infection. Liver, renal, and electrolyte studies may be done in addition, but the bone marrow biopsy is most important.

The nurse notes tiny purplish hemorrhagic spots under the skin while assessing a patient with a bleeding disorder. What term should the nurse use to document this finding? 1. Purpura 2. Macules 3. Petechiae 4. Ecchymoses

3 Petechiae are small hemorrhagic spots under the skin; large areas of discoloration are known as ecchymoses; and purpura is hemorrhage into the skin, mucous membranes, or organs. Any of these may be signs of hematological disorders. Macules, which would describe small flat lesions, would be a less accurate term.

The nurse is assisting with routine checks on a patient recently started on a blood transfusion. The nurse notices that the patient is short of breath and complains of chest pain and chills. What should the nurse do first? 1. Page the physician. 2. Check the patient's vital signs and lung sounds. 3. Stop the transfusion and stay with the patient while contacting the registered nurse (RN). 4. Note the reaction in the patient's chart and check back again in 10 minutes.

3 Shortness of breath, chest or back pain, fever, chills, and nausea are early signs of a hemolytic reaction to a blood transfusion. If the transfusion continues, the patient may develop shock and decreased consciousness, often leading to death. The transfusion should be stopped immediately, and the licensed practical nurse (LPN) should stay with the patient while instituting emergency procedures to notify the charge nurse and physician.

The nurse is providing care to infants in a well-child clinic. Which infant should the nurse assess for signs or symptoms of sickle cell anemia? 1. A 4-month-old infant girl who needs routine vaccinations 2. A 2-month-old infant boy whose left testicle has not descended 3. An 8-month-old infant boy who is recovering from an ear infection 4. A 1-week-old infant girl whose mother is having difficulty breastfeeding

3 Symptoms do not appear in infants until after the age of 6 months because up to that age the infant is using hemoglobin manufactured during fetal life, which is not affected by the sickling process.

The nurse is reviewing the laboratory results for a patient experiencing an allergic reaction. Which level should the nurse expect to be elevated in this patient? 1. Basophils 2. Monocytes 3. Eosinophils 4. Neutrophils

3 The different white blood cells are all involved in combating infection and inflammation, but each has a specific role. Eosinophils detoxify foreign proteins during allergic reactions, combat the effects of histamine, and respond to parasitic infections. Basophils are increased in hyperthyroidism, some bone marrow disorders, and ulcerative colitis. Monocytes are increased in chronic inflammatory disorders and some leukemias. Neutrophils are increased with an infection.

It is determined that a patient with anemia has a vitamin B12 deficiency. How should the nurse explain the role of vitamin B12 to the patient? 1. Vitamin B12 is synthesized by the stomach lining to metabolize iron within the body. 2. Vitamin B12 is metabolized by the liver to prevent the development of clotting disorders. 3. Vitamin B12 is obtained through food to support DNA synthesis of stem cells in the red bone marrow. 4. Vitamin B12 is excreted by the pancreas to facilitate the absorption of intrinsic factors in the small intestine.

3 Vitamin B12 is needed for DNA synthesis in the stem cells of the red bone marrow. It is called extrinsic factor because it comes from an extrinsic source: food. The parietal cells of the stomach lining produce intrinsic factor, which is a chemical that combines with vitamin B12 to promote its absorption in the small intestine. Vitamin B12 is not metabolized by the liver to prevent clotting disorders nor is it excreted by the pancreas to facilitate the absorption of intrinsic factors in the small intestines.

The nurse is caring for a patient who had a bone marrow transplant to treat aplastic anemia. The nurse would be most concerned if which symptom was noted? 1. Fatigue 2. Headache 3. Positive Homan's sign 4. Temperature = 101.2°F

4 A patient who has had a transplant is at high risk for infection, because the patient must take anti-rejection drugs that alter the immune system. The post-transplant patient is often kept in isolation for several weeks. In addition, a patient with aplastic anemia may have been given corticosteroids before the transplant, and they, too, increase the risk of infection. Fatigue is common with anemia and should gradually improve post-transplant. Positive Homan's sign could indicate a deep vein thrombosis, but the risk for this is much lower than the risk for infection. Headache is a vague symptom and not the priority at this time.

The nurse is reviewing the physiology of the red blood cells. Which body tissue or organ is responsible for the production of undifferentiated stem cells as the precursors for all blood cells? 1. Liver 2. Kidney 3. Thymus 4. Red bone marrow

4 All blood cells are produced by the red bone marrow, which is a blood-producing tissue found in flat bones, irregular bones, and the epiphyses of long bones. Final maturation of one type of white blood cell, T lymphocytes, occurs in the thymus; the kidneys respond to hypoxia by secreting erythropoietin, which increases the production of red blood cells. The liver stores and excretes the iron in hemoglobin and synthesizes clotting factors.

The LPN is assisting the RN to prepare a patient for a blood transfusion. The patient has a history of myocardial infarction and peripheral vascular disease. Which action will help reduce the risk of a transfusion reaction? 1. Palpate the patient's peripheral pulses. 2. Ask the patient to state name and birth date. 3. Assess for symptoms of an urticarial reaction. 4. Check the patient's pre-transfusion hemoglobin level.

4 Ensuring that the correct blood is administered will help prevent a hemolytic reaction. Assessing hemoglobin and peripheral pulses is appropriate, but will not prevent a reaction. Assessing for urticarial reaction is not needed, because the blood has not yet been infused.

The nurse is evaluating care provided to a patient with disseminated intravascular coagulation. Which laboratory result indicates that initial treatment for this health problem has been successful? 1. A decrease in Factors V, VII, VIII, X, and XIII 2. A decrease in hemoglobin and increase in blood urea nitrogen and serum creatinine 3. An increase in prothrombin time, partial thromboplastin, and fibrin degradation products 4. An increase in hemoglobin and platelet count and decrease in prothrombin time and partial thromboplastin time

4 In disseminated intravascular coagulation, there is an increase in prothrombin time, partial thromboplastin, and fibrin degradation products; a decrease in hemoglobin and platelet count; and an increase in blood urea nitrogen and serum creatinine levels. Laboratory results showing that these signs are changing (e.g., that hemoglobin and platelet counts are increasing and that clotting time, as indicated by prothrombin time and partial thromboplastin, is decreasing) indicate that initial treatment is working.

The nurse is reviewing laboratory results for patients in the oncology clinic. Which patient should the nurse recognize as being at the highest risk for altered tissue perfusion? 1. A 64-year-old male with a hematocrit = 41% 2. A 47-year-old female with a hematocrit = 38% 3. A 51-year-old male with a hemoglobin = 13.6 g/dL 4. A 59-year-old female with a hemoglobin = 9.7 g/dL

4 Red blood cells are responsible for carrying oxygen, and patients with anemia are at risk for altered tissue perfusion. Hemoglobin and hematocrit lab values both reflect anemia. The lab values are normal for all options except the hemoglobin of 9.7 g/dL, which is consistent with anemia.

The nurse is reviewing teaching provided to a patient with sickle cell anemia. Which patient statement indicates that teaching has been effective? 1. "I can enjoy skiing with my family in Colorado this winter." 2. "I can't wait to wear my new skinny jeans and over-the-knee boots!" 3. "I will cut my smoking down by only smoking a half a pack each day." 4. "I will look forward to talking long walks with my husband and dog on the weekends."

4 The patient should be instructed on ways to prevent sickle cell crisis. This includes avoiding strenuous exercise. Walking would not be strenuous and indicates that teaching has been effective. The patient should be instructed to avoid cold temperatures which would occur during skiing. Tight-fitting clothing like skinny jeans should be avoided because they restrict circulation. Smoking should be avoided because of vasoconstriction.

The nurse is reviewing the different types of blood disorders prior to participating in an inservice education session. Which blood disorder is characterized by bone marrow packed with an excess of blood cells that spill out into the circulation, leading to congested organs and a flushed appearance? 1. Thalassemia 2. Aplastic anemia 3. Polycythemia vera 4. Hemolytic anemia

In polycythemia vera, blood becomes so thick with too many red blood cells that it resembles sludge and cannot circulate throughout the body easily. The patient has a flushed complexion and may experience nosebleeds, exertional dyspnea, and chest pain. The other three responses are all forms of anemia in which there is a deficiency of red blood cells, hemoglobin, or both in the circulating blood. In hemolytic anemia, red blood cells are abnormally destroyed; in aplastic anemia, the bone marrow is incapable of producing the correct number of red blood cells. Thalassemia is a hereditary condition in which hemoglobin synthesis is impaired.