Hematology practice

33. A 19-year-old woman with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. The platelet count is 42,000/L. b. Petechiae are present on the chest. c. Blood pressure (BP) is 94/56 mm Hg. d. Blood is oozing from the venipuncture site

A Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/L unless the patient is actively bleeding. Therefore the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.

Significant information obtained from the patient's health history that relates to the hematologic system includes: a. jaundice b. bladder surgery c. early menopause d. multiple pregnancies

A - Jaundice is a common symptom that occurs with hematologic abnormalities. Jaundice is related to an accumulation of bile pigment that is caused by rapid or excessive hemolysis or liver damage.

When caring for a patient with thrombocytopenia, the nurse instructs the patient to: a. dab his or her nose instead of blowing b. be careful when shaving with a safety razor c. continue with physical activities to stimulate thrombopoiesis d. avoid Aspirin (ASA) because it may mask the fever that occurs with thrombocytopenia

A - Patients with thrombocytopenia should avoid aspirin because it reduces platelet adhesiveness, which contributes to bleeding. Patients should not perform vigorous exercise or lift weights. If a patient is weak and at risk for falling, supervise the patient when he or she is out of bed. Blowing the nose forcefully should be avoided. The patient should gently pat the nose with a tissue if needed. Instruct patients not to shave with a blade; an electric razor should be used.

In assessing the patient, which abnormal finding should the nurse relate to hemostasis abnormalities? a. purpura b. pruritus c. weakness d. pale conjunctiva

A - Purpura may occur when platelets or clotting factors are decreased and bleeding into the skin occurs. Pruritus is not related to hemostasis, but to hematologic cancers (e.g., lymphomas, leukemias) or increased bilirubin. Weakness and pale conjunctiva are not related to hemostasis unless a lot of bleeding leads to anemia with low Hgb level.

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find? a. elevated D-dimers b. elevated fibrinogen c. reduced prothrombin time (PT) d. reduced fibrin degradation products (FDPs)

A - The D-dimer is a specific marker for the degree of fibrinolysis and is elevated with DIC. FDP is elevated as the breakdown products from fibrinogen and fibrin are formed. Fibrinogen and platelets are reduced. PT, PTT, aPTT, and thrombin time are all prolonged.

The nurse is caring for a patient with a diagnosis of immune thrombocytopenic purpura (ITP). What is a priority nursing action in the care of this patient? a. Administration of packed red blood cells b. Administration of oral or IV corticosteroids c. Administration of clotting factors VIII and IX d. Maintenance of reverse isolation and application of standard precautions

B Common treatment modalities for ITP include corticosteroid therapy to suppress the phagocytic response of splenic macrophages. Blood transfusions, administration of clotting factors, and reverse isolation are not interventions that are indicated in the care of patients with ITP. Standard precautions are used with all patients.

27. Which information obtained by the nurse caring for a patient with thrombocytopenia should be immediately communicated to the health care provider? a. The platelet count is 52,000/µL. b. The patient is difficult to arouse. c. There are purpura on the oral mucosa. d. There are large bruises on the patient's back.

B Difficulty in arousing the patient may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The other information should be documented and reported but would not be unusual in a patient with thrombocytopenia.

14. Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura (ITP)? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.

B IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.

35. A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take? a. Avoid venipuncture. b. Notify the patient's physician. c. Apply sterile dressings to the sites. d. Give prescribed proton-pump inhibitors.

B The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions also are appropriate, but the most important action should be to notify the physician so that DIC treatment can be initiated rapidly.

What nursing intervention should be the priority in the care of a 30-year-old woman who has a diagnosis of immune thrombocytopenic purpura (ITP)? a. administration of packed red blood cells b. administration of oral or IV corticosteroids c. administration of clotting factors VIII and IX d. maintenance of reverse isolation and application of standard precautions

B - Common treatment modalities for ITP include corticosteroid therapy to suppress the phagocytic response of splenic macrophages. Blood transfusions, administration of clotting factors, and reverse isolation are not interventions that are indicated in the care of patients with ITP. Standard precautions are used with all patients.

The thrombocytopenic patient has had a bone marrow biopsy taken from the posterior iliac crest. What nursing care is the priority for this patient after this procedure? a. position the patient prone. b. apply a pressure dressing. c. administer analgesic for pain. d. return metal objects to the patient.

B - The sterile pressure dressing is applied after a bone marrow biopsy to ensure hemostasis. If bleeding is present, the patient will lie on the site and may need a rolled towel for additional pressure, thus this patient will not be in the prone position. The analgesic should have been administered preprocedure. Metal objects would be removed for an MRI, not a bone marrow biopsy.

A 30-year-old patient has undergone a splenectomy as a result of injuries suffered in a motor vehicle accident. Which phenomena are likely to result from the absence of the patient's spleen (select all that apply)? a. impaired fibrinolysis b. increased platelet levels c. increased eosinophil levels d. fatigue and cold intolerance e. impaired immunologic function

B, E - Splenectomy can result in increased platelet levels and impaired immunologic function as a consequence of the loss of storage and immunologic functions of the spleen. Fibrinolysis, fatigue, and cold intolerance are less likely to result from the loss of the spleen since coagulation and oxygenation are not primary responsibilities of the spleen.

DIC is a disorder in which: a. the coagulation pathway is genetically altered, leading to thrombus formation in all major blood vessels b. an underlying disease depletes hemolytic factors in the blood, leading to diffuse thrombotic episodes and infarcts c. a disease process stimulates coagulation processes with resultant thrombosis, as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage d. an inherited predisposition causes a deficiency of clotting factors that leads to overstimulation of coagulation processes in the vasculature

C - In disseminated intravascular coagulation (DIC), the coagulation process is stimulated, with resultant thrombosis and depletion of clotting factors, which leads to diffuse clotting and hemorrhage. The paradox of this condition is characterized by the profuse bleeding that results from the depletion of platelets and clotting factors.

After the diagnosis of disseminated intravascular coagulation (DIC), what is the first priority of collaborative care? a. administer heparin. b. administer whole blood. c. treat the causative problem. d. administer fresh frozen plasma.

C - Treating the underlying cause of DIC will interrupt the abnormal response of the clotting cascade and reverse the DIC. Blood product administration occurs based on the specific component deficiencies and is reserved for patients with life-threatening hemorrhage. Heparin will be administered if the manifestations of thrombosis are present and the benefit of reducing clotting outweighs the risk of further bleeding.

A patient with leukemia is admitted for severe hypovolemia after prolonged diarrhea has a platelet count of 43,000/µL. It is most important for the nurse to take which action? Insert two 18-gauge IV catheters. Administer prescribed enoxaparin. Monitor the patient's temperature every 2 hours. Check stools for presence of frank or occult blood.

D A platelet count below 150,000/µL indicates thrombocytopenia. Prolonged bleeding from trauma or injury does not usually occur until the platelet counts are below 50,000/µL. Bleeding precautions (e.g., check all secretions for frank and occult blood) are indicated for patients with thrombocytopenia. Injections (including IVs) should be avoided; however, when needed for critical fluids and medications, IV access should be provided through the smallest bore devices that are feasible. Enoxaparin, an anticoagulant administered subcutaneously, is contraindicated in patients with thrombocytopenia. Monitoring temperature would be indicated in a patient with leukopenia.

12. A patient who has been receiving a heparin infusion and warfarin (Coumadin) for a deep vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when her platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care? a. Use low-molecular-weight heparin (LMWH) only. b. Administer the warfarin (Coumadin) at the scheduled time. c. Teach the patient about the purpose of platelet transfusions. d. Discontinue heparin and flush intermittent IV lines using normal saline.

D All heparin is discontinued when the HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/µL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.

15. Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time

D Platelet aggregation in HIT causes neutralization of heparin, so that the activated partial thromboplastin time will be shorter and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.

When reviewing the patient's hematologic laboratory values after a splenectomy, the nurse would expect to find: a. leukopenia b. RBC abnormalities c. decreased hemoglobin d. increased platelet count

D - Splenectomy can have a dramatic effect in increasing peripheral RBC, white blood cell, and platelet counts.

When assessing laboratory values on a patient admitted with septicemia, what should the nurse expect to find? a. increased platelets b. decreased red blood cells c. decreased erythrocyte sedimentation rate (ESR) d. increased bands in the white blood cell (WBC) differential (shift to the left)

D - When infections are severe, such as in septicemia, more granulocytes are released from the bone marrow as a compensatory mechanism. To meet the increased demand, many young, immature polymorphonuclear neutrophils (bands) are released into circulation. WBCs are usually reported in order of maturity (initially with the less mature forms on the left side of a written report). Hence, the term "shift to the left" is used to denote an increase in the number of bands. Thrombocytosis occurs with inflammation and some malignant disorders. Decreased red blood cells indicate anemia. Decreased ESR is not indicative of septicemia.