NCLEX Hematology-Immune
A young adult client diagnosed with hemophilia develops painful swelling of the knee after bumping the leg. In caring for the client, which initial action is MOST appropriate for the nurse to take? 1. Apply ice to the knee and elevate the leg 2. Type and cross-match the client for 2 units of packed cells 3. Explain activity limitations to the client 4. Administer analgesics for pain
1. Apply ice to the knee and elevate the leg -- Hemophilia is a sex-linked recessive trait transmitted to males by female carriers. Clients have deficiency of factor VIII and experience abnormal bleeding in response to trauma. Painful swelling of the knee indicates acute bleeding into the joint. It is most important to instruct the client to institute supportive measures when trauma occurs, including rest, ice, compression and elevation (RICE). Applying ice to the knee and elevating the leg is the most appropriate action to take initially because it will help to stop the bleeding, decrease the swelling, and help alleviate the pain.
The nurse identifies which client is MOST likely to have latex hypersensitivity? 1. A client diagnosed with asthma 2. A client diagnosed with psoriasis 3. A client diagnosed with spina bifida 4. A client diagnosed with AIDS
3. A client diagnosed with spina bifida -- latex allergy is a serious health hazard for clients with spina bifida due to the repeated procedures and examinations these clients receive over the course of their lives. Clients have repeated exposure to latex containing products such as urinary catheters, examination gloves, bandages, adhesive tape, tourniquets, and EKG pads. Health care workers and people who routinely use latex condoms are also at high risk.
If a client has an anaphylactic reaction to an antibiotic, it is MOST important for the nurse to take which action after notifying the HCP? 1. Administer artificial respirations 2. Suction the airway 3. Start an IV infusion 4. Give epinephrine subQ
4. Give epinephrine subQ -- administer epi as soon as nurse identifies that client is having an anaphylactic reaction
The school nurse teaches a wellness class to a group of high school students. The nurse intervenes if a student makes which statement? 1. HIV is transmitted by sexual contact with an infected person 2. HIV can be transmitted by the sharing needles 3. A breastfeeding client who has HIV can infect the baby 4. HIV can be spread by using a public toilet
4. HIV can be spread by using a public toilet -- Casual contact cannot spread HIV. The HIV virus does not survive outside of the body and is not transmitted on shared surfaces such as toilet seats, dishes, or doorknobs. HIV is transmitted through specific body fluids; blood, semen, pre-seminal fluid, vaginal and rectal fluid and breast milk
The nurse provides care for a client diagnosed with AIDS. The client is reporting diarrhea. It is MOST important for the nurse to include which implementation in the client's plan of care? 1. Decrease roughage in the diet 2. Eat three meals per day 3. Increase intake of milk and cheese 4. Decrease intake of fluids
1. Decrease roughage in the diet -- The client should avoid foods that stimulate intestinal motility such as vegetables and fruits, fatty, spicy and sweet foods, alcohol and caffeine
The nurse cares for a client diagnosed with immune thrombocytopenia purpura. Which nursing diagnosis is a priority when caring for this client? 1. Risk for injury 2. Risk for infection 3. Potential for fluid volume deficit 4. Risk for sensory-perceptual alterations
1. Risk for injury -- protect client from situation that can cause bleeding; monitor closely; avoid IM injections, apply firm pressure after needlestick; ice areas of trauma; test urine and stool for occult blood, use electric razor and avoid mouth trauma
The home care nurse visits a client diagnosed with AIDS. The nurse intervenes if which observation of the caregiver is made? 1. The caregiver asks guests if they are sick before visiting the client 2. The caregiver disinfects the bathroom with a 1:10 solution of household bleach 3. The caregiver places soiled linens in a laundry hamper 4. The caregiver washes the dishes in the dishwasher
3. The caregiver places soiled linens in a laundry hamper -- if the linen is soiled with blood, vomit, semen, vaginal fluids, urine or feces, remove them with disposable gloves. Wash immediately or as soon as possible. If there is a delay in getting the items washed, put them in plastic bag.
An older client is diagnosed with anemia. The client lives in a two-story house, and the bedrooms are on the second floor. Prior to discharge, it is most important for the nurse to ask which question? 1. How often does you adult child plan to visit 2. Shall I arrange Meals-on-Wheels for you? 3. Where do you plan to sleep? 4 . Is your laundry in the basement?
3. Where do you plan to sleep? -- Fatigue is a complication of anemia. The client may be too fatigued to climbing stairs. If necessary, nurse needs to arrange for client to have a bed on the first floor until the anemia is resolved. Encourage the client to balance rest and activity.
The nurse reviews the medical record for a client diagnosed with hemophilia. It is most important for the nurse to the question which entry? 1. Apply a splint to the left knee 2. Acetaminophen with codeine 1 tablet PO q 4 hr for pain 3. Vital signs q 4hr 4. Meperidine 75 mg IM q4h prn for severe pain
4. Meperidine 75 mg IM q4h prn for severe pain -- IM injections should be avoided for the client diagnosed with hemophilia due to the high risk bleeding into the tissue. The nurse should contact the HCP to question this prescribed medication.
The nurse cares for a client diagnosed with confusion due to AIDS dementia complex. It is MOST important for the nurse to take which action? 1. Ask the client to identify the day and date 2. Assist the client to answer questions asked by the family 3. Give the client simple directions 4. Explain the day's schedule during breakfast
3. Give the client simple directions -- when communicating with the client diagnosed with AIDS dementia complex, the nurse should use short, uncomplicated sentences.
The nurse in the hematology clinic prepares a class series on immunologic diseases for new clients. Which organs does the nurse describes as part of the immune system of the body? 1. Spleen and thymus 2. Liver and kidneys 3. Heart and lungs 4. Gall bladder and pancreas
1. Spleen and thymus - the spleen has both nonimmunologic and immunologic functions. The spleen is considered part of the lymphatic system and has functions of immunologic defense such as routinely cleansing the blood of microorganisms by macrophages and producing leukocytes, monocytes and lymphocytes. The removal of the spleen or diminished function from infection or injury greatly increases the risk for bacterial infections. The thymus is an endocrine organ responsible for development of T-lymphocytes which, when mature, are called T-cells. These have cytotoxic properties and can destroy "target" cells.
The nurse obtains a history from a client with a diagnosis of sickle cell anemia. The client is admitted with a diagnosis of vaso-occlusive crisis. The nurse identifies which factor most contributed to the vaso-occlusive crisis? 1. The client recently had an upper respiratory infection 2. The client has type 1 diabetes 3. The client drinks tea at dinner 4. The client attended a child's graduation yesterday
1. The client recently had an upper respiratory infection -- Sickle cell disease is a severe hemolytic anemia resulting from defective hemoglobin. In the presence of low oxygen, the client's hemoglobin becomes sick-shaped and red blood cells clump together obstructing capillary blood flow. Symptoms of vaso-occlusive crisis include pain and jaundice. Infection and dehydration can precipitate a vaso-occlusive crisis.
A client with pernicious anemia asks the nurse how long injections of Vitamin B12 will be needed. Which response by the nurse is the best? 1. You may need lifelong injections 2. Ask your HCP 3. Six months to a year 4. That will be determined by your blood count
1. You may need lifelong injections -- Pernicious anemia is a type of vitamin B12 anemia. The body needs vitamin B12 to make RBCs. If the client has severe pernicious anemia injections may be given every day or every week until the B12 level stabilizes. Once the B12 levels are normal, injections may only need to be given once per month. For less severe cases, vitamin B12 oral tablets or nose gel/spray may be an option.
The community health nurse teaches a class on disease prevention at a community health fair. One of the participants states, "I have heard the term incubation period but I do not know what it means. What is it exactly" Which is the best response by the nurse? 1. Incubation period is the time for a new medication to be tested before it is brought into the market 2. Incubation period is the time between when a person gets infected and when actual symptoms appear 3. Incubation period is the time it takes between when a vaccine is administered and when it takes effects 4. Incubation period is the recommended time period for a newborn to be kept in an incubator or isolette
2. Incubation period is the time between when a person gets infected and when actual symptoms appear
The nurse assesses a client reporting fatigue and shortness of breath due to AIDS. Which action does the nurse do first? 1. Refer the client to occupational therapy 2. Instruct the client to sit while preparing meals 3. Instruct the client to perform all activities in the morning 4. Suggest to the client that accepting limitations is best.
2. Instruct the client to sit while preparing meals -- is an energy conservation technique. Other energy conserving techniques while cooking include using convenient and easy-to-prepare foods, preparing the kitchen so it has easy to access to frequently used items, soaking dishes instead of scrubbing them, and preparing double portion meals and freezing half of them.
The nurse understands which is the most common type of anemia? 1. Aplastic anemia 2. Iron-deficiency anemia 3. Pernicious anemia 4. Sickle cell anemia
2. Iron-deficiency anemia -- is a condition of a decrease in the number of erythrocytes or a reduction in hemoglobin. Symptoms include dyspnea, chronic fatigue, paleness, severe palpitations, sensitivity to cold, and profound weakness. Iron deficiency anemia is caused by blood loss, increased metabolic energy demands, GI malabsorption and dietary inadequacy Other info: 1. Aplastic anemia is a rare disease condition due to bone marrow depression. Treatment includes blood transfusions, immunosuppressive therapy, and stem cell transplant 2. CORRECT 3. Pernicious anemia is a caused by the inability of gastric mucosa to absorb vitamin B12 due to deficiency of intrinsic factor 4. Sickle cell anemia is an autosomal recessive genetic disorder seen most frequently in African Americans.
An older client is diagnosed with iron deficiency anemia. The client states that even though an "iron pill" is taken daily, the client is feeling more and more fatigued. Which action does the nurse take first? 1. Instruct the client to balance rest and activity 2. Obtain a stool specimen to test for occult blood 3. Contact the health care provider 4. Instruct the client about eating foods high in iron
2. Obtain a stool specimen to test for occult blood -- a major cause of iron-deficiency anemia in adults is bleeding. Bleeding is frequently found in the GI system. The nurse should carefully assess the GI system; the character of emesis, stools, diarrhea, anorexia, n/v
The nurse understands that hematocrit measures which data about the blood? 1. Oxygen-carrying capacity of the blood 2. Ratio of RBCs to fluid volume 3. Number of RBCs in 100 mL of blood 4. Ratio of RBCs to WBCs
2. Ratio of RBCs to fluid volume -- HCT is the ratio of red blood cells to fluid volume. Normal range for a male is 42-52% (0.42-0.52), a female is 35 - 47% and a child aged 3-12 years is 35 - 45% Other info: 1. Oxygen-carrying capacity of the blood -- Hemoglobin (Hgb). Normal Hgb for male is 13 - 18, a female 12 - 16, and a child 3 - 12 years of age is 11 - 12.5 Hgb. 2. CORRECT 3. Number of RBCs in 100 mL of blood -- The RBC count determines the actual number of cells in relation to volume 4. Ratio of RBCs to WBCs -- the WBC count establishes the amount and maturity of WBC elements. Hct is not a measurement related to WBC count.
Several days following bone marrow aspiration, the nurse notes the client has a temperature of 103 F (39.5 C), and there is yellow drainage from the aspiration site. Which interpretation by the nurse is most accurate? 1. The client's condition is worsening 2. The client developed osteomyelitis 3. The client has contaminated the site 4. The client is showing a normal response
2. The client developed osteomyelitis -- the client has developed osteomyelitis, a potential complication of bone marrow aspirations. Fever and yellow, purulent discharge from the site are signs of osteomyelitis. Bleeding is another complication but is typically a more immediate occurrence. To prevent bleeding, the nurse should apply pressure to the site for several minutes.
The nurse provides care for clients on the medical/surgical unit. The nurse identifies which client has an autoimmune disease? 1. The client diagnosed with pellagra 2. The client diagnosed with MS 3. The client diagnosed with Bell palsy 4. The client diagnosed with scoliosis
2. The client diagnosed with MS -- the exact cause of MS is unknown, but MS is considered an autoimmune disorder with viral and genetic components. It is a chronic progressive disease characterized by deterioration of the myelin sheath of the CNS and subsequent scarring via plagues throughout the brain and spinal cord. S/S: include ataxia, weakness, spasticity, nystagmus, paresthesias, incontinence, and emotional instability. Treatment include comfort measures, exercises, medications, ambulations training, and the use of self-help devices.
A spouse of a client diagnosed with pernicious anemia asks why vitamin B12 cannot be given in pill form. Which response by the nurse is best? 1. Your spouse's symptoms of deficiency are quite severe, and large doses can only be given by injection 2. Your spouse's stomach doesn't secrete the necessary substance for B12 to be absorbed orally 3. I can ask the HCP to change the medication to a pill of your spouse does not want an injection 4. The IM route is the fastest way for vitamin B12 to be absorbed
2. Your spouse's stomach doesn't secrete the necessary substance for B12 to be absorbed orally -- Vitamin B12 is given by injection because the client's gastric mucosa can not secrete intrinsic factor which allows oral preparations to be absorbed. Vitamin B12 obtained from dietary sources is normally absorbed by means of intrinsic factor found in the stomach. For a client without intrinsic factor, vitamin B12 must be provided IM.
The nurse counsels a client diagnosed with iron deficiency anemia. The nurse determines teaching is effective if the client selects which menu? 1. Broiled fish, green veggies and milk 2. Fried chicken, yellow veggies, and fruit juice 3. Flank steak, green leafy veggies, and prunes 4. Grilled cheese sandwich, creamed soup, and tomato soup
3. Flank steak, green leafy veggies, and prunes
The nurse provides care for a client with sickle cell anemia diagnosed with a vaso-occlusive crisis. The client's child comes to visit the parent, and the nurse observes the child has an upper respiratory infection. It is most important for the nurse to take which action? 1. Inform the child that visiting the client cannot occur 2. Instruct the child to stand at least 6 feet from the client 3. Give the child a mask to wear when visiting the client 4. Demonstrate to the child the correct way to put on a gown and gloves.
3. Give the child a mask to wear when visiting the client
The nurse understands which finding best describes what clients diagnosed with disseminated intravascular coagulation (DIC) experience? 1. Hemorrhage 2. Clotting 3. Hemorrhage and clotting 4. Widespread collateral circulation development
3. Hemorrhage and clotting -- DIC is a coagulation disorder resulting in an overstimulation of the normal clotting cascade and results in simultaneous thrombosis (clotting) and hemorrhage (bleeding). Microclots from and affect tissue perfusion in the major organs, causing hypoxia, ischemia, and tissue damage. Coagulation occurs in the two different pathways: intrinsic and extrinsic. These pathways are responsible for the formation of fibrin clots and blood clotting, which maintains homeostasis. In the intrinsic pathway, endothelial cell damage may occur because of sepsis or infection. The extrinsic pathway is triggered by tissue injury from malignancy, trauma, or an obstetrical complications. Treatment consists of correcting the precipitating cause, replacing clotting factors and platelets, and controlling the manifestations of both thrombosis and the hemorrhage.
The nurse teaches a client diagnosed with iron deficiency anemia about diet. The nurse determines teaching is successful if the client selects which menu items? 1. Chicken salad, lettuce and tomatoes and an apple 2. Roast beef sandwich, coleslaw, and ice cream 3. Liver and onions, spinach and rice pudding with raisins 4. Cheese omelet, toast and fruit cocktail
3. Liver and onions, spinach and rice pudding with raisins
The nurse provides care for a client diagnosed with polycythemia vera. The nurse expects to make which assessment? 1. Jaundice 2. Hematocrit <48% 3. Ruddy (reddish) complexion 4. Hypotension
3. Ruddy (reddish) complexion -- Symptoms of polycythemia vera occur as a result of increased blood volume and viscosity. Symptoms from an increase in blood volume include headache, dizziness, tinnitus, fatigue, paresthesias, and blurred vision. Symptoms related to blood viscosity may include angina, claudication, dyspnea, thrombophlebitis and an elevated BP Other info: 1. Jaundice - polycythemia vera is a condition where the body makes extra red blood cells which causes hyperviscosity (thickening) of the blood. The blood can form clots more easily which can cause occlusions in the veins and arteries putting the client at risk for a heart attack or stroke. Polycythemia vera does not cause jaundice 2. The client's hematocrit will be elevated (over 55%) because of the overproduction of RBC. The client's superficial veins may also be distended 3. CORRECT 4. HTN occurs due to increased viscosity of the blood
Which symptom best indicates to the home health nurse that a client has an infection? 1. The client has a rash 2. The client has a heart murmur 3. The client has lymphadenopathy 4. The client has nystagmus
3. The client has lymphadenopathy -- Lymphadenopathy is an enlargement of lymph nodes in the body to the point where they are palpable. The nodes function as a filter of foreign material such as bacteria and also aid in the circulation of lymphocytes such as T-cells. Lymphocytes fight infection and increase in number when infection is present. Other info: 1. The client has a rash -- may indicate infection, such as a communicable disease, but it may indicate many other situations as well, such as an allergic reaction 2. The client has a heart murmur -- is not indicative of infection. A heart murmur is an abnormal sound heard during auscultation of the heart. It reflects turbulent blood flow through valves that may be normal or abnormal 3. CORRECT 4. The client has nystagmus -- is not indicative of infection. It is involuntary, oscillating, rhythmic, or jerking movements of the eyes, usually side to side but may be in any direction. It can occur in a wide variety of situations, such as labyrinth problems in the ears, neurologic disorders such as MS and toxicity to certain medications such as phenobarbital.
The nurse prepares a client for a Schilling test. Which information is most important for the client to know before starting the test? 1. How the vitamin B12 is measured 2. Why radioactivitiy is used 3. How the results will be interpreted 4. How to collect a 24-hour urine
4. How to collect a 24-hour urine -- part of the Schilling test includes the collection of urine for 24 hours. The client must comply carefully with collecting the urine over a 24-hour period. The nurse will instruct the client void and discard urine, the start of the 24-hour collection of the urine begins thereafter. The client will save all urine during the specified time in one container that is refrigerated or kept on ice. The client will label the container with the exact date and time that the collection started and ended. Other info: 1. A Schilling test is used to diagnose pernicious anemia. The client fasts for 12 hours and is then given a small dose of radioactive B12 orally, followed by a large, nonradioactive dose IM. The client then will collect a 24 hour urine. If the urine is not radioactive, the radioactive B12 stayed in the GI tract
The parents of a newly circumcised infant client are informed that their child has hemophilia A. One parent is crying and expresses concern that the child will "bleed to death". The other parent says, "just give me the facts. we will deal with it". It is MOST important for the nurse to give the parents which information initially? 1. The necessity for avoiding contact sports and other potentially injurious activities 2. The importance of a diet high in protein, carbs and calories 3. The improvements in psychological counseling related to coping with life-long limitations 4. The availability of replacement therapy of clotting factors
4. The availability of replacement therapy of clotting factors -- addressing the availability of clotting factors is the most important information for the nurse to give initially because it is accurate information and will most immediately address the fears of the parents. Hemophilia results from either a deficiency of factor VII or factor IX clotting factors in the blood. Antihemophilic factor (AHF) replacement therapy is the primary therapy for this disorder. Circumcision, initial ambulation or initial tooth eruption are times when severe hemophilia is often first detected
The nurse provides care for a client experiencing a vaso-occlusive crisis. The nurse determines care is appropriate if which observation is made? 1. The client's room is 62 F (18 C) 2. The client's intake is limited for 48 hours 3. The client understands the limitations for pain control 4. The client receives regular neurological assessments
4. The client receives regular neurological assessments -- the nurse will monitor for changes in the level of consciousness, reports of h/a and dizziness, development of sensory and motor deficits, and seizure activity. Neurological changes may reflect diminished perfusion to the CNS
