Prep U: Chpt. 39 Management of Patients with Nonmalignant Hematologic Disorders

A clinical nurse specialist (CNS) is orienting a new graduate registered nurse to an oncology unit where blood product transfusions are frequently administered. In discussing ABO compatibility, the CNS presents several hypothetical scenarios. The new graduate knows that the greatest likelihood of an acute hemolytic reaction would occur when giving:

A-positive blood to an A-negative client. An acute hemolytic reaction occurs when there is an ABO or Rh incompatibility. For example, giving A blood to a B client would cause a hemolytic reaction. Likewise, giving Rh-positive blood to an Rh-negative client would cause a hemolytic reaction. It's safe to give Rh-negative blood to an Rh-positive client if there is a blood type compatibility. O-negative blood is the universal donor and can be given to all other blood types. AB clients can receive either A or B blood as long as there isn't an Rh incompatibility.

Which is a symptom of hemochromatosis?

Bronzing of the skin Clients with hemochromatosis exhibit symptoms of weakness, lethargy, arthralgia, weight loss, and loss of libido early in the illness trajectory. The skin may appear hyperpigmented from melanin deposits or appear bronze in color.

The nurse and the client are discussing some strategies for ingesting iron to combat the client's iron-deficiency anemia. Which is among the nurse's strategies?

Drink liquid iron preparations with a straw. Dilute liquid preparations of iron with another liquid such as juice and drink with a straw to avoid staining the teeth. Avoid taking iron simultaneously with an antacid, which interferes with iron absorption. Drink orange juice or take other forms of vitamin C with iron to promote its absorption.

A male client has a hemoglobin count of 10.2 gm/dl, a hematocrit value of 36%, and a low ferritin level. What question should the nurse ask first?

Have you experienced abdominal pain? The laboratory data support that the client has iron-deficiency anemia. The most common cause of iron-deficiency anemia in men is bleeding from ulcers, gastritis, inflammatory bowel disease, or gastrointestinal tumors. People who experience these problems may report abdominal pain. The nurse will make further assessments and may ask the other questions.

Which term refers to an abnormal decrease in white blood cells, red blood cells, and platelets?

Pancytopenia Pancytopenia is defined as an abnormal decrease in WBCs, RBCs, and platelets. The condition may be congenital or acquired. Anemia refers to decreased red cell mass. Leukopenia refers to a less-than-normal amount of WBCs in circulation. Thrombocytopenia refers to a lower-than-normal platelet count.

The nurse is screening donors for blood donation. Which client is an acceptable donor for blood?

Reports having a cold 1 month ago that resolved quickly Donors must meet certain requirements to be able to donate blood. A client should be in good health, such as the client who had a cold more than 1 month ago that resolved quickly. Those excluded from donating blood have a history of viral hepatitis, report a blood transfusion within 12 months, and had a dental extraction within 72 hours. The reason for exclusion is that they are at increased risk of transmitting an infectious disease.

A patient is taking prednisone 60 mg per day for the treatment of an acute exacerbation of Crohn's disease. The patient has developed lymphopenia with a lymphocyte count of less than 1,500 mm3. What should the nurse monitor the client for?

The onset of a bacterial infection Lymphopenia (a lymphocyte count less than 1,500/mm3) can result from ionizing radiation, long-term use of corticosteroids, uremia, infections (particularly viral infections), some neoplasms (e.g., breast and lung cancers, advanced Hodgkin disease), and some protein-losing enteropathies (in which the lymphocytes within the intestines are lost) (Kipps, 2010). When lymphopenia is mild, it is often without sequelae; when severe, it can result in bacterial infections (due to low B lymphocytes) or in opportunistic infections (due to low T lymphocytes).

After receiving chemotherapy for lung cancer, a client's platelet count falls to 98,000/mm3. What term should the nurse use to describe this low platelet count?

Thrombocytopenia

When evaluating a patient's symptoms that are consistent with a diagnosis of leukemia, the nurse is aware that all leukemias have which common feature?

Unregulated accumulation of white cells in the bone marrow, which replace normal marrow elements The term leukemia means "white blood," which is used to describe the neoplastic proliferation of one hematopoietic cell type (granulocytes, monocytes, lymphocytes, and sometimes, erythrocytes and megakaryocytes).

A client with sickle cell anemia has a

low hematocrit. A client with sickle cell anemia has a low hematocrit and sickled cells on the smear. A client with sickle cell trait usually has a normal hemoglobin level, a normal hematocrit, and a normal blood smear.

A few minutes after beginning a blood transfusion, a nurse notes that a client has chills, dyspnea, and urticaria. The nurse reports this to the health care provider immediately because the client probably is experiencing which problem?

A hemolytic allergic reaction caused by an antigen reaction Hemolytic allergic reactions are fairly common and may cause chills, fever, urticaria, tachycardia, dyspnea, chest pain, hypotension, and other signs of anaphylaxis a few minutes after blood transfusion begins. Although rare, a hemolytic reaction to mismatched blood can occur, triggering a more severe reaction and, possibly, leading to disseminated intravascular coagulation. A hemolytic reaction to Rh-incompatible blood is less severe and occurs several days to 2 weeks after the transfusion. Bacterial contamination of donor blood causes a high fever, nausea, vomiting, diarrhea, abdominal cramps and, possibly, shock.

A client is brought to the ED reporting fatigue, large amounts of bruising on the extremities, and abdominal pain localized in the left upper quadrant. A health history reveals the client has been treated for a sore throat three times in the past 2 months. Laboratory tests indicate severe anemia, significant neutropenia, and thrombocytopenia. Based on the symptoms, what could be the client's diagnosis?

Aplastic anemia Aplastic anemia can be congenital or acquired, but most cases are idiopathic. It can be triggered by infection. The manifestations of aplastic anemia are symptoms of anemia, purpura (bruising), retinal hemorrhages, significant neutropenia, and thrombocytopenia. Other lymphadenopathies and splenomegaly sometimes occur.

A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor?

As renal function decreases, erythropoietin, which is produced by the kidney, also decreases. Because erythropoietin is produced outside the kidney, some erythropoiesis continues, even in patients whose kidneys have been removed. However, the number of red blood cells produced is small and the degree of erythropoiesis is inadequate.

The nurse cares for a client with iron deficiency anemia. What findings will the nurse expect to find when reviewing the client's CBC results? Select all that apply. Decreased MCV Increased MCV Decreased reticulocytes Increased reticulocytes Fragmented RBCs

Decreased MCV Decreased reticulocytes

The nurse provides care for an older adult client, diagnosed with anemia, who has a hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine the cause of the client's blood loss, which is the priority nursing action?

Observe the client's stools for blood. If an older adult is anemic, blood loss from the gastrointestinal (GI) or genitourinary (GU) tracts is suspected. Observing the stool for blood will determine if the source of the client's bleeding is in the GI tract. Iron-deficiency anemia is unusual in older adults because the body does not eliminate excessive iron, thus increasing total body iron stores and necessitating maintenance of hydration. If evaluation of the GI and GU tracts does not reveal a source of bleeding, evaluating the client's diet may be appropriate; however, this is not the priority nursing action. Monitoring the client's body temperature and BP will assist the nurse in determining the source of the client's blood loss, but these are not priority nursing actions.

A nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?

Use the smallest needle possible for injections. Because thrombocytopenia alters coagulation, it poses a high risk of bleeding. To help prevent capillary bleeding, the nurse should use the smallest needle possible when administering injections. The nurse doesn't need to limit visits by family members because they don't pose any danger to the client. The nurse should provide comfort measures and maintain the client on bed rest; activities such as using a wheelchair can cause bleeding. The nurse records fluid intake and output to monitor hydration; however, this action doesn't protect the client from a complication of thrombocytopenia.

A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client?

Vascular occlusion in small vessels decreasing blood and oxygen to the tissues. The person with sickle cell disease repeatedly suffers from two major problems: (1) episodes of sickle cell crisis from vascular occlusion, which develops rapidly under hypoxic conditions, and (2) chronic hemolytic anemia. During a sickle cell crisis, the sickle-shaped cells lodge in small blood vessels, where they block the flow of blood and oxygen to the affected tissue. The vascular occlusion induces severe pain in the ischemic tissue. The client may have increased tolerance for pain due to the chronic nature of the illness. Bone marrow increases the erythrocyte production. Underhydration increases the client's risk of developing a vaso-occlusive crisis.

A client's family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC?

"DIC is caused by abnormal activation of the clotting pathway, causing excessive amounts of tiny clots to form inside organs." The inflammatory response initiates the process of inflammation and coagulation. The natural anticoagulant pathways within the body are simultaneously impaired, and the fibrinolytic system is suppressed, allowing a massive amount of tiny clots forms in the microcirculation. As the platelets and clotting factors form microthrombi, coagulation fails. Thus, the paradoxical result of excessive clotting is bleeding. Decline in organ function is usually a result of excessive clot formation (with resultant ischemia to all or part of the organ).

A client with megaloblastic anemia reports mouth and tongue soreness. What instruction will the nurse give the client regarding eating while managing the client's symptoms?

"Eat small amounts of bland, soft foods frequently." Because the client with megaloblastic anemia often reports mouth and tongue soreness, the nurse should instruct the client to eat small amounts of bland, soft foods frequently. The other answer choices do not factor in the client's mouth soreness or need for nutrition.

The nurse is collecting data for a client who has been diagnosed with iron-deficiency anemia. What subjective findings does the nurse recognize as symptoms related to this type of anemia?

"I have difficulty breathing when walking 30 feet." Most clients with iron-deficiency anemia have reduced energy, feel cold all the time, and experience fatigue and dyspnea with minor physical exertion. The heart rate usually is rapid even at rest. The CBC and hemoglobin, hematocrit, and serum iron levels are decreased. The client would feel cold and not hot. The client is fatigued and able to sleep often with a decrease in appetite, not an increase.

A home care nurse visits a client diagnosed with atrial fibrillation who is ordered warfarin. The nurse teaches the client about warfarin therapy. Which statement by the client indicates the need for further teaching?

"I'll eat four servings of fresh, dark green vegetables every day." The client requires additional teaching if he states that he'll eat four servings of dark green vegetables every day. Dark, green vegetables contain vitamin K, which reverses the effects of warfarin. The client should limit his intake to one to two servings per day. The client should report bleeding gums and severe or unexplained bruising, which may indicate an excessive dose of warfarin. The client should use an electric razor to prevent cutting himself while shaving.

A client's low prothrombin time (PT) was attributed to low vitamin K levels and the client's PT normalized after administration of vitamin K. When performing discharge education in an effort to prevent recurrence, what should the nurse emphasize?

Adequate nutrition Vitamin K deficiency is often the result of a nutritional deficit. NSAIDs do not influence vitamin K synthesis and clotting factors are not necessary to treat or prevent a vitamin K deficiency. Hygiene is not related to the onset or prevention of vitamin K deficiency.

A client with sickle cell crisis is admitted to the hospital in severe pain. While caring for the client during the crisis, which is the priority nursing intervention?

Administering and evaluating the effectiveness of opioid analgesics The priority nursing intervention is to manage the acute pain. Client-controlled analgesia is frequently used in the acute care setting. A patient with sickle cell crisis experiences severe extreme pain, the use of IV fluids and oral intake is need to hydrate the patient, the patient is initially placed on bed rest during the crisis due to extreme fatigue. The patient must continue to ingest folic acid and are placed on a daily folic acid supplement .

Which of the following is the most common hematologic condition affecting elderly patients

Anemia Anemia is the most common hematologic condition affecting elderly patients: with each successive decade of life, the incidence of anemia increases. Thrombocytopenia is a low platelet count. Leukopenia is a low leukocyte count. Bandemia is an increased number of band cells.

When teaching a client with iron deficiency anemia about appropriate food choices, the nurse encourages the client to increase the dietary intake of which foods?

Beans, dried fruits, and leafy, green vegetables Food sources high in iron include organ meats (e.g., beef or calf liver, chicken liver), other meats, beans (e.g., black, pinto, and garbanzo), leafy and green vegetables, raisins, and molasses. Taking iron-rich foods with a source of vitamin C (e.g., orange juice) enhances the absorption of iron.

A male client has been receiving a continuous infusion of weight-based heparin for more than 4 days. The client's PTT is at a level that requires an increase of heparin by 100 units per hour. The client has the laboratory findings shown above. What is the most important action for the nurse to take?

Consult with the physician about discontinuing heparin. Platelet counts may decrease with heparin therapy, and this client's platelet count has decreased. The client may have heparin-induced thrombocytopenia (HIT). Treatment of HIT includes discontinuing the heparin. The question asks about the most important action of the nurse and that is to consult with the physician about discontinuing heparin therapy. The nurse may continue with the current rate and should not increase the heparin dose until consulting with the physician. Warfarin is not administered until the platelet count has returned to normal levels.

A patient with chronic renal failure is examined by the health care provider for anemia. Which laboratory results will the nurse monitor?

Decreased level of erythropoietin As renal function decreases, erythropoietin, which is produced by the kidney, also decreases. Because erythropoietin is produced outside the kidney, some erythropoiesis continues, even in patients whose kidneys have been removed. However, the number of red blood cells produced is small and the degree of erythropoiesis is inadequate.

A thin client is prescribed iron dextran intramuscularly. What is most important action taken by the nurse when administering this medication?

Employs the Z-track technique When iron medications are given intramuscularly, the nurse uses the Z-track technique to avoid local pain and staining of the skin. The gluteus maximus muscle is used. The nurse avoids rubbing the site vigorously and uses a 18- or 20-gauge needle.

The nurse observes the laboratory studies for a client in the hospital with fatigue, feeling cold all of the time, and hemoglobin of 8.6 g/dL and a hematocrit of 28%. What finding would be an indicator of iron-deficiency anemia?

Erythrocytes that are microcytic and hypochromic A blood smear reveals erythrocytes that are microcytic (smaller than normal) and hypochromic (lighter in color than normal). It does not reveal macrocytic (larger than normal) or hyperchromic erythrocytes. Clustering of platelets with sickled red blood cells would indicate sickle cell anemia. An increase in the number of erythrocytes would indicate polycythemia vera.

A patient with End Stage Kidney Disease is taking recombinant erythropoietin for the treatment of anemia. What laboratory study does the nurse understand will have to be assessed at least monthly related to this medication?

Hemoglobin level When using recombinant erythropoietin, the hemoglobin must be checked at least monthly (more frequently until a maintenance dose is established) and the dose titrated to ensure the hemoglobin level does not exceed 12 g/dL.

A client with severe anemia reports symptoms of tachycardia, palpitations, exertional dyspnea, cool extremities, and dizziness with ambulation. Laboratory test results reveal low hemoglobin and hematocrit levels. Based on the assessment data, which nursing diagnoses is most appropriate for this client?

Ineffective tissue perfusion related to inadequate hemoglobin and hematocrit The symptoms indicate impaired tissue perfusion due to a decrease in the oxygen-carrying capacity of the blood. Cardiac status should be carefully assessed. When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly) and by peripheral edema.

The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned the co-worker may have?

Iron deficiency anemia People with iron deficiency anemia may crave ice, starch, or dirt; this craving is known as pica.

The nurse is performing an assessment for a client with anemia admitted to the hospital to have blood transfusions administered. Why would the nurse need to include a nutritional assessment for this patient?

It may indicate deficiencies in essential nutrients. A nutritional assessment is important, because it may indicate deficiencies in essential nutrients such as iron, vitamin B12, and folate.

A client with a diagnosis of pernicious anemia comes to the clinic and reports numbness and tingling in the arms and legs. What do these symptoms indicate?

Neurologic involvement In clients with pernicious anemia, numbness and tingling in the arms and legs, and ataxia are the most common signs of neurologic involvement. Some affected clients lose vibratory and position senses. Jaundice, irritability, confusion, and depression are present when the disease is severe. Insufficient intake of dietary nutrients is not indicated by these symptoms.

A client with multiple myeloma is complaining of severe pain when the nurse comes in to give a bath and change position. What is the priority intervention by the nurse?

Obtain the pain medication and delay the bath and position change until the medication reaches its peak. When pain is severe, the nurse delays position changes and bathing until an administered analgesic has reached its peak concentration level and the client is experiencing maximum pain relief. Pain medication should never be delayed to assist in the control of the level of pain. Pain will not be relieved by a bath and clean sheets, only analgesics at this point in the client's illness.

A nurse is caring for a client with iron deficiency anemia. Which food or beverage will the nurse suggest to the client to eat or drink when taking supplemental iron?

Orange juice Vitamin C found in orange juice improves the absorption of iron. The other answer choices are not the best for improving absorption of iron.

A nurse is caring for a client with severe anemia. The client is tachycardic and reports dizziness and exertional dyspnea. What signs and symptoms might develop if this client goes into heart failure?

Peripheral edema Cardiac status should be carefully assessed in clients with anemia. When the hemoglobin level is low, the heart attempts to compensate by pumping faster and harder in an effort to deliver more blood to hypoxic tissue. This increased cardiac workload can result in such symptoms such as tachycardia, palpitations, dyspnea, dizziness, orthopnea, and exertional dyspnea. Heart failure may eventually develop, as evidenced by an enlarged heart (cardiomegaly) and liver (hepatomegaly), and by peripheral edema. Nausea, migraine, and fever are not associated with heart failure.

While monitoring a client for the development of disseminated intravascular coagulation (DIC), the nurse should take note of which assessment parameters?

Platelet count, prothrombin time, and partial thromboplastin time The diagnosis of DIC is based on the results of laboratory studies of prothrombin time, platelet count, thrombin time, partial thromboplastin time, and fibrinogen level as well as client history and other assessment factors. Blood glucose levels, WBC count, calcium levels, and potassium levels aren't used to confirm a diagnosis of DIC.

A client awaiting a bone marrow aspiration asks the nurse to explain where on the body the procedure will take place. What body part does the nurse identify for the client?

Posterior iliac crest In adults, bone marrow is usually aspirated from the posterior iliac crest and rarely from the sternum. Bone marrow is not aspirated from the femur or ankle.

A nurse cares for clients with hematological disorders and notes that women are diagnosed with hemochromatosis at a much lower rate than men. What is the primary reason for this?

Women lose iron through menstrual cycles Hemochromatosis is a genetic condition where excess iron is absorbed in the GI tract and deposited in various organs, making them dysfunctional. Women are often less affected than men because women lose excess iron through their menstrual cycles. The other answer choices are not correct reasons why women are impacted less than men with hemochromatosis.

A nurse cares for a client with anemia after having a total gastrectomy a year ago. Which unique assessment findings will the nurse likely find when assessing this client that may not be present in another client with anemia? Select all that apply. Tingling in the fingers Shortness of breath Fatigue Weakness Poor coordination

tingling in the fingers poor coordination The client likely has pernicious anemia, caused by a lack of intrinsic factor, found in the stomach. Paresthesias (tingling in the fingers) and poor coordination are unique to pernicious anemia. Shortness of breath, fatigue, and weakness are common to other anemias and not unique assessment findings.