Hinkle Chapter 32: Assessment of Hematologic Function and Treatment Modalities

A nurse is teaching a client with a vitamin B12 deficiency about appropriate food choices to increase the amount of B12 ingested with each meal. The nurse knows the teaching is effective based on which statement by the client?

"I will eat a meat source such as chicken or pork with each meal" Vitamin B12 is found only in foods of animal origin. The other choices do not include meats. Dairy products contain large amounts of Calcium and vitamin D. Orange vegetables contain large amounts of vitamin A.

A nurse cares for a client with megaloblastic anemia who had a total gastrectomy three years ago. What statement will the nurse include in the client's teaching regarding the condition?

"This condition is most likely caused by a vitamin B12 deficiency" Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12 -intrinsic factor complex is absorbed in the distal ileum. Clients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and the absorption of vitamin B12 may be diminished. Megaloblastic anemia may be caused by a folate deficiency; however, the client's history of gastrectomy indicates the likely cause is a vitamin B12 deficiency. Megaloblastic anemia causes large erythrocytes (RBCs), not small or rigid.

A preoperative client is discussing blood donation with the nurse. Which statement by the client indicates to the nurse the need for further teaching?

"my family will donate blood because it is safer" Directed donations from friends and family members are not any safer than those provided by random donors. Withdrawal of 450 mL of blood usually takes about 15 minutes. Specimens from donated blood are tested to detect infections and to identify the specific blood type. Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high.

A client with a history of congestive heart failure has an order to receive 1 unit of packed red blood cells (RBCs). If the nurse hangs the blood at 12:00 pm, by what time must the infusion be completed?

4:00 PM When packed red blood cells (PRBCs) or whole blood is transfused, the blood should be administered within a 4-hour period because warm room temperatures promote bacterial growth.

When conducting a health assessment on a client suspected for having a hematological disorder, the nurse should collect which data? Select all that apply.

Dietary intake Medication use Ethnicity Herbal supplements Dietary intake, ethnicity, use of herbal supplements, and medication use are factors for which the nurse should assess. Hair color is not considered a factor in determining causes of hematological disorders.

During a blood transfusion with packed red blood cells (RBCs), a client reports chills, low back pain, and nausea. What priority action should the nurse take?

Discontinue the infusion immediately and maintain the IV line with normal saline solution using new IV tubing The following steps are taken to determine the type and severity of the reaction: Stop the transfusion. Maintain the IV line with normal saline solution through new IV tubing, administered at a slow rate. Assess the client carefully. Notify the physician. Continue to monitor the client's vital signs and respiratory, cardiovascular, and renal status. Notify the blood bank that a suspected transfusion reaction has occurred. Send the blood container and tubing to the blood bank for repeat typing and culture.

A client with severe anemia is admitted to the hospital. Because of religious beliefs, the client is refusing blood transfusions. The nurse anticipates pharmacologic therapy with which drug to stimulate the production of red blood cells?

Epoetin alpha Erythropoietin (epoetin alfa) is an effective alternative treatment for clients with chronic anemia secondary to diminished levels of erythropoietin. This medication stimulates erythropoiesis. Filgratism ( Neupogen) and Sargramostim stimulate granulocytosis( increasing WBC count) , Eltrombopag (Promacta) is used to treat aplastic anemia and thrombocytopenia.

A client receiving a blood transfusion experiences an acute hemolytic reaction. What is the nurse's priority intervention?

Immediately stop the transfusion, infuse normal saline solution, call the health care provider, and notify the blood bank. When a transfusion reaction occurs, the transfusion should be immediately stopped, normal saline solution should be infused to maintain venous access, and the health care provider and blood bank should be notified immediately. Other nursing actions include saving the blood bag and tubing, rechecking the blood type and identification numbers on the blood tags, monitoring vital signs, obtaining necessary laboratory blood and urine samples, providing proper documentation, and monitoring and treating for shock. Because they can cause red blood cell hemolysis, dextrose solutions shouldn't be infused with blood products. Antihistamines are administered for a mild allergic reaction, not a hemolytic reaction.

An older adult client presents to the health care provider's office and reports exhaustion. The nurse, aware of the most common hematologic condition affecting the elderly, knows that which laboratory values should be assessed?

RBC count A decreased red blood cell count is indicative of anemia, a common condition in older adults that results in fatigue.

A nurse cares for several mothers and babies in the postpartum unit. Which mother does the nurse recognize as being most at risk for a febrile nonhemolytic reaction?

Rh-negative mother; Rh-positive child A mother who is Rh negative and gives birth to an Rh positive child is at greatest risk for a febrile nonhemolytic reaction because exposure to an Rh-positive fetus raises antibody levels in the Rh negative mother. An Rh-negative mother can carry an Rh-negative child without being at greatest risk for a febrile nonhemolytic reaction; however, these mothers are often treated prophylactically. An Rh-positive mother may carry either an Rh-positive or Rh-negative child without increased risk.

Place the following procedural steps in order for transfusing a unit of packed red blood cells (PRBCs).

Start an intravenous line. Obtain the unit of PRBCs from the blood bank. Double check the labels with another nurse to ensure correct ABO group and Rh type. Initiate the blood transfusion within 30 minutes of receipt. Monitor closely for signs of a transfusion reaction. The nurse should first start an intravenous line, obtain the PRBCs, double check labels, start the transfusion, and then monitor for a reaction.

Place the following steps in order when determining the type and severity of a transfusion reaction. Use all options.

Stop the transfusion. Assess the client. Notify the health care provider. Notify the blood bank. Send the tubing and container to the blood bank. It is important for the nurse to take the proper steps when determining the type and severity of a transfusion reaction. The priority action is to stop the infusion and then assess the client. Next, the health care provider will be notified, followed by the blood bank. Finally, the nurse should send the tubing and container to the blood bank for analysis.

A nurse, caring for a client with human immunodeficiency virus (HIV), reviews the client's differential WBC count. What type of WBC will the nurse check the level of?

T lymphocytes Lymphocytes (T cells, B cells, and natural killer cells) are WBCs that are the major components of the body's immune response. T cells are primarily responsible for cell-mediated immunity, whereas B cells are involved in antibody production.

Which type of lymphocyte is responsible for cellular immunity?

T-lymphocyte T lymphocytes are responsible for delayed allergic reactions, rejection of foreign tissue (e.g., transplanted organs), and destruction of tumor cells. This process is known as cellular immunity. B lymphocytes are responsible for humoral immunity. A plasma cell secretes immunoglobulin. A basophil contains histamine and is an integral part of hypersensitivity reactions.

The nurse is caring for a client with hypoxia. What does the nurse understand is true regarding the client's oxygen level and the production of red blood cells?

The kidneys sense low oxygen levels in the blood and stimulate erythropoietin, stimulating the marrow to produce more red blood cells. If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (as with anemia), erythropoietin levels increase, stimulating the marrow to produce more erythrocytes (red blood cells).

The nurse is obtaining the health history of a client suspected of having a hematological condition. The nurse notes the client has a history of alcohol abuse. Which clinical presentation is related to alcohol consumption?

anemia Individuals with a history of alcohol consumption may have anemia due to nutritional deficiencies. Myelodysplastic syndrome, neutropenia, and thrombocytopenia are not common findings in clients who consume or abuse alcohol.

The physician performs a bone marrow biopsy from the posterior iliac crest on a client with pancytopenia. What intervention should the nurse perform after the procedure?

apply pressure over the site for 5-7 minutes Hazards of either bone marrow aspiration or biopsy include bleeding and infection. The risk of bleeding is somewhat increased if the client's platelet count is low or if the client has been taking a medication (e.g., aspirin) that alters platelet function. After the marrow sample is obtained, pressure is applied to the site for several minutes. The site is then covered with a sterile dressing.

Which type of leukocyte contains histamine and is an important part of hypersensitivity reactions?

basophil Basophils contain histamine and are an integral part of hypersensitivity reactions. B lymphocytes are responsible for humoral immunity. A plasma cell secretes immunoglobulins. The neutrophil functions in preventing or limiting bacterial infection via phagocytosis.

The nurse is caring for a client who had undergone hemodilution during surgery. Immediately after surgery, the nurse expects to see which lab result?

decreased hematocrit The added intravenous solutions used in hemodilution dilute the concentration of erythrocytes and lower the hematocrit. Adverse outcomes include tissue ischemia, particularly in the kidneys. These adverse outcomes can be manifested as low arterial oxygen saturation and elevated creatinine levels.

A patient with chronic kidney disease is being examined by the nurse practitioner for anemia. The nurse has reviewed the laboratory data for hemoglobin and RBC count. What other test results would the nurse anticipate observing?

decreased level of erythropoietin Differentiation of the primitive myeloid stem cell into an erythroblast is stimulated by erythropoietin, a hormone produced primarily by the kidney. If the kidney detects low levels of oxygen, as occurs when fewer red cells are available to bind oxygen (i.e., anemia), or with people living at high altitudes with lower atmospheric oxygen concentrations, erythropoietin levels increase. The increased erythropoietin then stimulates the marrow to increase production of erythrocytes. The entire process of erythropoiesis typically takes 5 days (Cook, Ineck, & Lyons, 2011). For normal erythrocyte production, the bone marrow also requires iron, vitamin B12, folate, pyridoxine (vitamin B6), protein, and other factors. A deficiency of these factors during erythropoiesis can result in decreased red cell production and anemia.

The nurse expects which assessment finding when caring for a client with a decreased hemoglobin level?

decreased oxygen level Hemoglobin carries oxygen; a decreased hemoglobin level results in decreased oxygen. An elevated temperature is a sign of infection and can result from decreased white blood cells. Arterial blood is more oxygen saturated and brighter red in color than venous blood. Increased bruising results from a decreased platelet level, not decreased hemoglobin.

A client receiving a unit of packed red blood cells (PRBCs) has been prescribed morphine 1 mg intravenously now for pain. What is the best method for the nurse to administer the morphine?

disconnect the blood tubing, flush with normal saline, and administer morphine Never add medications to blood or blood products. The transfusion must be temporarily stopped in order to administer the morphine.

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 a 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 client receiving a blood transfusion reports shortness of breath, appears anxious, and has a pulse of 125 beats/minute. What is the best action for the nurse to take after stopping the transfusion and awaiting further instruction from the health care provider?

ensure there is an oxygen delivery device at the bedside The client is exhibiting signs of circulatory overload. After stopping the transfusion and notifying the healthcare provider, the nurse should place the client in a more upright position with the legs dependent to decrease workload on the heart. The IV line is kept patent in case emergency medications are needed. Oxygen and morphine may be needed to treat severe dyspnea. Administering an anti-anxiety agent is not a priority action over ensuring oxygen is available.

A client with chronic kidney disease has chronic anemia. What pharmacologic alternative to blood transfusion may be used for this client?

erythropoietin Erythropoietin (epoetin alfa [Epogen, Procrit]) is an effective alternative treatment for clients with chronic anemia secondary to diminished levels of erythropoietin, as in chronic renal disease. This medication stimulates erythropoiesis.

A patient is undergoing platelet pheresis at the outpatient clinic. What does the nurse know is the most likely clinical disorder the patient is being treated for?

essential thrombocythemia Platelet pheresis is used to remove platelets from the blood in patients with extreme thrombocytosis or essential thrombocythemia (temporary measure)or in a single-donor platelet transfusion.

A client wants to donate blood before his or her abdominal surgery next week. What should be the nurse's first action?

explain the time frame needed for autologous donation Preoperative autologous donations are ideally collected *4 to 6 weeks before surgery*. The nurse should first explain that time frame to this client. Surgery is scheduled in one week which means that autologous blood donation may not be an option for this client. A list of donation centers can be provided to the client; and even though iron is recommended and 2 units of blood may be suggested, the first action is to tell the client about the needed time frame for donation.

Which term refers to the percentage of blood volume that consists of erythrocytes?

hematocrit Hematocrit is the percentage of blood volume consisting of erythrocytes. Differentiation is development of functions and characteristics that differ from those of the parent stem cell. ESR is a laboratory test that measures the rate of settling of RBCs; an elevated rate is indicative of inflammation. Hemoglobin is the iron-containing protein of RBCs.

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?

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.

After withdrawing the needle from blood donor's arm, the site begins to bleed excessively. What is the nurse's first action?

hold firm pressure on the venipuncture site Excessive bleeding at the venipuncture site may be caused by not applying enough pressure at the site. Applying a tourniquet will exacerbate the bleeding. After applying pressure, the arm should be raised above heart level. Helping the client into an erect position will not help stop the bleeding.

Splenic sequestration is diagnosed in a client admitted with splenomegaly. What is the priority of care for this client?

hypovolemia If the spleen is enlarged, a greater proportion of red cells and platelets can be sequestered. With less red blood cells in circulation, the client can become hypovolemic resulting in shock. Decreased white blood cells in circulation, not red blood cells, increases the chance of infection. Decreased circulatory volume results in hypotension, not hypertension. Hyperthermia is not a result of decreased red blood cells in circulation.

A nurse cares for a client with myelodysplastic syndrome who requires frequent PRBC transfusions. What blood component does the nurse recognize as being most harmful if accumulated in the tissues due to chronic blood transfusions?

iron Iron overload is a complication unique to people who have had long-term PRBC transfusion. Over time, the excess iron deposits in body tissues can cause organ damage, particularly in the liver, heart, testes, and pancreas.

The client's CBC with differential reveals small-shaped hemoglobin molecules. The nurse expects to administer which medication to this client?

iron With iron deficiency, the erythrocytes produced by the marrow are small and low in hemoglobin. Vitamin B12 and folate deficiencies are characterized by the production of abnormally large erythrocytes. Fresh frozen plasma are infused due to a low platelet level, not light-colored hemoglobin.

A patient who has long-term packed RBC (PRBC) transfusions has developed symptoms of iron toxicity that affect liver function. What immediate treatment should the nurse anticipate preparing the patient for that can help prevent organ damage?

iron chelation therapy Iron overload is a complication unique to people who have had long-term PRBC transfusions. One unit of PRBCs contains 250 mg of iron. Patients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. Over time, the excess iron deposits in body tissues and can cause organ damage, particularly in the liver, heart, testes, and pancreas. Promptly initiating a program of iron chelation therapy can prevent end-organ damage from iron toxicity.

A client reports feeling faint after donating blood. What is the nurse's best action?

keep the client in recumbent position to rest After blood donation, the donor should remain recumbent until he or she feels able to sit up. Donors who experience weakness or faintness should rest for a longer period. High-Fowler's position would not promote blood flow to the brain, and could cause the client to feel light-headed or faint. Ambulating a client who feels faint is not safe due to the high risk of falling. Trendelenburg position is not recommended after blood donation.

The nurse is preparing a patient for a bone marrow aspiration and biopsy from the site of the posterior superior iliac crest. What position will the nurse place the patient in?

lateral position with one leg flexed Bone marrow aspiration procedure. The posterior superior iliac crest is the preferred site for bone marrow aspiration and biopsy because no vital organs or vessels are nearby. The patient is placed either in the lateral position with one leg flexed or in the prone position.

Which blood cell type is matched correctly with its function?

leukocyte: fights infection Various blood cell types have unique, major functions. Leukocytes fight infection, T lymphocytes are integral in cell-mediated immunity, plasma cells secrete immunoglobulin, and B lymphocytes are integral in humoral immunity.

Albumin is important for the maintenance of fluid balance within the vascular system. Albumin is produced by which of the following?

liver Albumin is produced by the liver. Albumin is not produced in the pancreas, kidney, or large intestine.

Which term refers to a form of white blood cell involved in immune response?

lymphocyte Both B and T lymphocytes respond to exposure to antigens. Granulocytes include basophils, neutrophils, and eosinophils. A spherocyte is a red blood cell without central pallor, seen with hemolysis. A thrombocyte is a platelet.

A nurse is reviewing a client's morning laboratory results and notes a left shift in the band cells. Based on this result, the nurse can interpret that the client

may be developing an infection Less mature granulocytes have a single-lobed, elongated nucleus and are called band cells. 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. An increased number of band cells is sometimes called a left shift or shift to the left. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of white blood cells in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.

Vitamin B and folic acid deficiencies are characterized by production of abnormally large erythrocytes called

megaloblasts Megaloblasts are abnormally large erythrocytes. Blast cells are primitive WBCs. Mast cells are cells found in connective tissue involved in defense of the body and coagulation. Monocytes are large WBCs that become macrophages when they leave the circulation and move into body tissues.

Which cell of hematopoiesis is responsible for the production of red blood cells (RBCs) and platelets?

myeloid stem cell Myeloid stem cells are responsible not only for all nonlymphoid white blood cells (WBC) but also for the production of red blood cells and platelets. Lymphoid cells produce either T or B lymphocytes. A monocyte is large WBC that becomes a macrophage when is leaves the circulation and moves into body tissues, and not responsible for RBC production.. A neutrophil is a fully mature WBC capable of phagocytosis and not responsible for RBC production.

The body responds to infection by increasing the production of white blood cells (WBCs). The nurse should evaluate the differential count for what type of WBCs, which are the first WBCs to respond to an inflammatory event?

neutrophils Neutrophils, the most abundant type of white blood cell, are the first of the WBCs to respond to infection or inflammation. The normal value is 3,000 to 7,000/cmm (males) and 1,800 to 7,700/cmm (females).

Under normal conditions, the adult bone marrow produces approximately 70 billion neutrophils. What is the major function of neutrophils?

phagocytosis The major function of neutrophils is phagocytosis. T lymphocytes are responsible for rejection of foreign tissue and destruction of tumor cells. Plasma cells produce antibodies call immunoglobulin.

The client is diagnosed with polycythemia vera. The nurse prepares the client for which procedure?

phlebotomy Polycythemia vera is a condition in which the blood contains a large amount of red blood cells, increasing the viscosity of the blood. Phlebotomy is a preferred treatment to rid the circulation of excess red blood cells. Apheresis is a process in which platelets and leukocytes are removed from the blood. Blood and platelet infusions can exacerbate this condition.

A nurse is assisting a client into position prior to bone marrow aspiration. Which position will the nurse place the client prior to the procedure?

prone Prior to the bone marrow aspiration, the nurse should place the client in either the prone position or lateral position with one leg flexed. The aspiration usually is performed on the anterior iliac crest. It would not be appropriate for the nurse to place the client in supine, knee-chest, or Trendelenburg positions.

The nurse is working at a blood donation clinic. What teaching should the nurse provide to the donor immediately after blood donation?

remain for observation after eating and drinking After blood donation, the donor receives food and fluids and is asked to remain for observation. After the needle is removed, donors are asked to hold the involved arm straight up, and firm pressure is applied with sterile gauze for 2 to 3 minutes. A firm bandage is then applied. The donor remains recumbent until he or she feels able to sit up, usually within a few minutes.

A nurse reviews a client's laboratory results and notes the client has a decreased lymphocyte count. What nursing diagnosis will the nurse use when planning the client's care?

risk for infection Lymphocytes act as the killer cells for viruses and cancer cells. If lymphocytes are decreases, the client is at a greater risk of infection. The other nursing diagnoses would not apply to the client's clinical presentation.

A nurse is caring for a client with a diagnosis of lymphocytopenia. Which assessment finding will the nurse consider most concerning when caring for this client?

temperature 37.7 degrees Celsius Lymphocytopenia is a decrease in the number of lymphocytes. Lymphocytes help to fight foreign invaders, such as infectious organisms. A temperature of 37.7 degree Celsius is a Fahrenheit temperature of 99.9. A low-grade fewer may be indicative of an infection. The other answer choices do not suggest infection and are not the priority concern.

The nurse is administering a blood transfusion to a client over 4 hours. After 2 hours, the client reports chills and has a fever of 101°F, an increase from a previous temperature of 99.2°F. What does the nurse recognize is occurring with this client?

the client is having a febrile nonhemolytic reaction The signs and symptoms of a febrile nonhemolytic transfusion reaction are chills (minimal to severe) followed by fever (more than 1°C elevation). The fever typically begins within 2 hours after the transfusion is begun. Although the reaction is not life threatening, the fever, and particularly the chills and muscle stiffness, can be frightening to the client.

A nursing instructor is reviewing the role and function of stem cells in the bone marrow with a group of nursing students. After providing the explanation, the instructor asks the students to use their knowledge of anatomy and physiology to determine an alternate way in which adults with diseases that destroy marrow can resume production of blood cells. Which explanation by the students is correct?

the liver and spleen can resume the production of blood cells through extramedullary hematopoiesis In adults with disease that destroy marrow or cause fibrosis or scarring, the liver and spleen can also resume production of blood cells through a process known as extramedullary hematopoiesis.

A patient will need a blood transfusion for the replacement of blood loss from the gastrointestinal tract. The patient states, "That stuff isn't safe!" What is the best response from the nurse?

"I understand your concern. The blood is carefully screened but is not completely risk free." Despite advances in donor screening and blood testing, certain diseases can still be transmitted by transfusion of blood components (Chart 32-4).

Which client is not a candidate for blood donation according to the American Heart Association?

26 year old female with hemoglobin 11.0 g/dL Clients must meet the following criteria to be eligible as blood donors: body weight at least 50 kg; pulse rate regular between 50 and 100 bpm; systolic BP 90 to 180 mmHg and diastolic 50 to 100 mmHg; hemoglobin level at least 12.5 g/dL for women. There is no upper age limit to donation.

A nurse is preparing a dose of furosemide for an older adult with heart failure. The health care provider orders furosemide 1 mg/kg to be given intravenously. The client weighs 50 kg. The concentration of the drug is 40 mg/4mL (10 mg/mL). How many milliliters would the nurse administer? Record your answer using a whole number.

5 1 mg/kg X 50 kg = 50 mg then divide by 10 mg/mL = 5 mL

The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise?

Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Isometric exercise induce contraction of skeletal muscle so that it compresses the walls of veins and increases the circulation of venous blood as it returns to the heart. Isometric exercises do not have an aerobic effect and should not increase the heart rate; although, it may increase blood pressure. Isometric exercise does not decrease the workload of the heart. Arterial flow moves blood flow away from the heart after being oxygenated.

A nurse cares for a client who has had a bone marrow aspiration. In addition to the client's aspiration site, what locations on the body does the nurse recognize as having bone marrow? Select all that apply.

Pelvis Ribs Vertebrae Sternum Bone marrow can be found in the pelvis, ribs, vertebrae, and sternum. Additionally, bone marrow is found on the spongy end of the femur and humerus long bones. The tibia does not have bone marrow.

A client with a history of sickle cell anemia has developed iron overload from repeated blood transfusions. What treatment does the nurse anticipate will be prescribed?

chelation therapy Chelation therapy is prescribed to treat iron overload. Hepatitis B immunization helps immunize against hepatitis B. Red blood cell phenotyping helps decreased sensitization. A white blood cell filter protects against cytomegalovirus and some sensitization and febrile reactions.

The nurse should be alert to which adverse assessment finding when transfusing a unit of packed red blood cells (PRBCs) too rapidly?

crackles auscultated bilaterally Increasing the flow rate of a blood transfusion too rapidly can result in circulatory overload. Fluid overload can be manifested by crackles in the lungs. A decreased respiratory rate and decreased temperature are not manifestations of fluid overload. Pain and tenderness in the calf area may indicate a thrombosis which is not as common a manifestation as fluid overload.

What food should the nurse recommend for a client diagnosed with vitamin B12 deficiency?

lean meat Vitamin B12 is only found in foods of animal origin. Therefore, whole-grain bread, green vegetables, and citrus fruit do not contain this vitamin.

Which is a symptom of severe thrombocytopenia?

petechiae Clients with severe thrombocytopenia have petechiae, which are pinpoint hemorrhagic lesions, usually more prominent on the trunk or anterior aspects of the lower extremities.

While caring for a client, the nurse notes petechiae on the client's trunk and lower extremities. What precaution will the nurse take when caring for this client?

use an electric razor when assisting patient with shaving Petechiae are associated with severe thrombocytopenia, placing the client at risk for bleeding. The nurse should use an electric razor when assisting the client with shaving. Elevating the head of the bed and applying supplemental oxygen would be appropriate for a client with decreased oxygenation. Wearing a mask when entering the client's room would be appropriate for a client with neutropenia, not thrombocytopenia.

The client is to receive a unit of packed red blood cells. What is the nurse's first action?

verify that the client has signed a written consent form All the options are interventions the nurse will do to ensure the blood transfusion is safe. The question asks about the first action of the nurse. The first action would be verifying that the client has signed a written consent form. Then, the nurse would ensure the intravenous site has a 20-gauge or larger needle. The nurse would proceed to obtain the unit of blood, check the blood with another registered nurse, and observe for gas bubbles in the unit of blood.

The physician orders a transfusion with packed red blood cells (RBCs) for a client hospitalized with severe iron deficiency anemia. When blood is administered, what is the most important action the nurse can take to prevent a transfusion reaction?

verify the clients identity according to the hospital policy Acute hemolytic transfusion reactions are preventable. Improper identification is responsible for the majority of hemolytic transfusion reactions. Meticulous attention to detail in labeling blood samples and blood components and accurately identifying the recipient cannot be overemphasized. It is the nurse's responsibility to ensure that the correct blood component is transfused to the correct client. The nurse must assess the client during the initial start of the transfusion and frequently, if the nurses delays the assessment time for 30 minutes the client may have begun to experience acute hemolytic transfusion reaction, this puts the client's safety at risk.

A client comes into the emergency department reporting an enlarged tongue. The tongue appears smooth and beefy red in color. The nurse also observes a 5-cm incision on the upper left quadrant of the abdomen. When questioned, the client states, "I had a partial gastrostomy 2 years ago." Based on this information, the nurse attributes these symptoms to which problem?

vitamin 12 deficiency Because vitamin B12 is found only in foods of animal origin, strict vegetarians may ingest little vitamin B12. Vitamin B12 combines with intrinsic factor produced in the stomach. The vitamin B12-intrinsic factor complex is absorbed in the distal ileum. Clients who have had a partial or total gastrectomy may have limited amounts of intrinsic factor, and therefore the absorption of vitamin B12 may be diminished. The effects of either decreased absorption or decreased intake of vitamin B12 are not apparent for 2-4 years. This results in megaloblastic anemia. Some symptoms are a smooth, beefy red, enlarged tongue and cranial nerve deficiencies.