UW hematology

A client on a med-surg unit is receiving heparin therapy. Platelet levels decreased from 230,000 two days ago to 80,000 today. Which nursing actions are appropriate? SATA A. Confirm validity of platelet result with new blood specimen B. Hold the scheduled morning dose of heparin C. Notify the provider of the platelet count D. Obtain a full set of vital signs E. Request a change of prescription from heparin to enoxaprin.

Ans A,B,C,D A significant reduction in platelets after the initiation of heparin therapy can indicate heparin-induced thrombocytopenia (HIT) a serious and potentially lethal complication. HIT is an immune reaction to heparin that causes a drastic Decrease > 50% in platelets and a paradoxical increase in arterial and venous thrombosis. The nurse should notify the provider immediately and should anticipate stopping heparin therapy and initiating a non-heparin anticoagulant (eg. warfarin). Clients with HIT have increased risk for DVT and pulmonary embolism. The nurse should perform a neurovascular assessment and report evidence of vascular clots (eg. DVT) to the provider. The nurse should also measure a full set of v/s to assess for a PE. When large changes are noted in lab values, it is important to redraw samples to confirm those values.

The nurse provides care for a patient diagnosed with Polycythemia Vera. Which statement by the client would require immediate follow-up? A. "I am trying to find makeup to cover up my unattractive, ruddy facial complexion." B. "I must have injured my leg in some way. It is sore swollen and red." C. "I take baby aspirin to relieve my occasional headaches." D. "My skin itches so severely and no lotion or cream seems to help."

Ans B Polycythemia Vera (PV) is a hematological disorder in which too many RBCs (and often WBC and Platelets) are produced causing increased blood viscosity , venous stasis and increased risk for thrombus formation. The nurse should teach the client with PV measures to prevent thrombus (e.g. wearing graduated compression stockings, elevate legs with sitting, maintaining adequate hydration. Clients should learn to monitor for and report s/sx of thrombus (eg. redness, tenderness, or swelling in one leg). Reports of possible thrombus require immediate intervention to avoid serious injury (eg. stroke, pulmonary embolism).

A client with polycythemia vera comes to the clinic for a monthly treatment. The nurse knows that treatment for this condition will consist of which of the following? A. Blood transfusion B. Fluid bolus C. Phlebotomy D. Steroid injection

Ans. C Polycythemia vera is a chronic myeloproliferative disorder in which the bone marrow produces an abnormally high number of RBCs. Although PV is an abnormality of the bone marrow, secondary polycythemia can occur in an individual with chronic hypoxemia, such as COPD or chronic lung disease. The danger of PV is seen when the client develops blood clots-due to the increased viscosity of the blood, which makes the circulation sluggish-and decreased tissue perfusion. Treatment of PV usually includes periodic phlebotomy, the removal of 300-500mL of blood through venipuncture, to reduce the RBC count and achieve a hematocrit is reached. Hematocrit is then monitored monthly, and additional blood draws are performed as necessary.

The nurse is reviewing morning laboratory results after receiving report. Which client should the nurse assess first? A. Client on a heparin infusion whose platelet count decreased from 175,000 to 86,000. B. Client with dehydration with blood urea nitrogen of 24 mg/dL C. Client with myelodysplastic syndrome with white blood cell count of 2,000 D. Client with sickle cell disease whose hemoglobin decreased from 6.1 mg/dL to 7.9 mg/dL

Ans: A Heparin-induced thrombocytopenia Clinical features:Heparin exposure > 5 days and any of the following: -Drop in platelet count by>50% -Arterial or venous thrombosis -Necrotic skin lesions at heparin injection site -Anaphylactoid reaction after heparin Diagnosis: -Serotonin release assay Treatment: -Stop all heparin products -Start nonheparin medication HIT is a potentially life-threatening immune reaction to heparin that causes a decrease in platelets of >50% from baseline or a drop below 150,000 over several days (eg. 5-10 days). HIT can lead to paradoxical venous and/or arterial thrombosis that can cause organ damage, stroke, pulmonary embolism, and death. All heparin products must be stopped immediately and a different anticoagulant (eg. argatroban) must be prescribed. Therefore, the nurse should first assess the client on a heparin drip whose platelet count has decreased by 50%.

The nurse provides home care education to a client newly diagnosed with Von Willebrand disease. Which of the following client statements demonstrate correct understanding of the education? SATA A. "I can use a humidifier to help prevent nosebleeds." B. "I need to avoid contact sports such as soccer of hockey." C. "I should use a soft-bristled toothbrush and floss carefully." D. "I will call my health care provider if I soak a menstrual pad every hour." E. "I will take naproxen to decrease inflammation if I am injured."

Ans: A,B,C,D Von Willebrand disease is a genetic bleeding disorder caused by a deficiency of Von Willebrand factor, which plays an important role in coagulation. Intranasal desmopressin or topical therapies (eg. Thrombin) may be prescribed to stop minor bleeding, whereas major bleeding may require replacement of Von Willebrand factor. Clients should wear medical identification bracelets in case of emergency. Client teaching includes: -Notify the HCP of signs of bleeding -Use a humidifier or nasal spray to keep mucosa moist, reducing the risk of nosebleeds -Avoid aspirin and NSAIDS -Avoid activities with a higher risk for injury -Maintain gum integrity -Report heavy menstrual bleeding which can be managed with hormonal therapies and intranasal desmopressin.

The nurse is caring for a client with hemophilia admitted for a facial laceration and hemarthrosis of the left knee after falling at home. Which of the following actions by the nurse are appropriate? SATA A. Administers coagulation factor replacement IV push B. Administers ibuprofen PO PRN for pain C. Applies ice packs to the affected joint hourly for 15 minutes D. Elevates the affected leg in the extended position E. Performs neurologic assessment every 30 minutes for 6 hours

Ans: A,C,D,E Hemophilia is a group of disorders characterized by deficiencies in production or use of coagulation proteins (eg. factor VIII, factor IX), resulting in impaired clot formation and increased risk for uncontrolled bleeding. Hemophilia is typically identified by prolonged or excessive bleeding, severe bruising, or joint bleeding (ie. hemarthrosis) after injuries or procedures. Administration of supplemental IV clotting factors (eg. factor VIII and factor IX) is the primary treatment for acute bleeding in clients with hemophilia. Clients with hemophilia have increased risk of hemarthrosis (ie. bleeding in joint). In addition to administration of IV clotting factors, hemarthrosis is managed with rest, ice, compression and elevation (RICE). Application of ice or cold packs promotes local vasoconstriction and clot formation. The affected joint should be maintained in the extended position to prevent flexion contracture. Frequent neurologic assessments are required for clients with hemophilia who have suspected (facial laceration in this client)or confirmed head trauma, as neurologic alteration may indicate intracranial bleeding.

The nurse plans discharge teaching for a client newly diagnosed with polycythemia vera. Which actions will the nurse include in the teaching plan? SATA A. Elevate the legs and feet when sitting B. Increase dietary intake of foods rich in iron C. Increase fluid intake during exercise and hot water D. Increase water temperature to reduce post-bath itching E. Report swelling or tenderness in the legs

Ans: A,C,E Polycythemia vera is a chronic disorder of the bone marrow in which too many red blood cells, white cells, and platelets are produced. Clients with PV are at risk of developing blood clots due to increased blood volume and viscosity. Clients are instructed to elevate the legs and feet when sitting, wear support stockings, and report signs of thrombosis. Adequate fluid intake during exercise and hot weather is important to reduce fluid loss and decrease viscosity

The nurse is preparing to administer medications to a client with an asthma exacerbation. Which prescription should the nurse confirm with the health care provider prior to administration? Lab Values Day 1 Day 5 Hematocrit 37% 36% platelets 250,000 96,000 WBC 9,100 15,000 Potassium 3.8 3.6 A. Albuterol 2.5 mg per nebulizer every 4 hours B. Enoxaprin 40 mg subcutaneously every 24 hours C. Methylprednisolone succinate 20 mg IV every 6 hours D. Potassium Chloride 20 mEq IV every 24 hours

Ans: B A significant reduction in platelets after initiation of heparin or low-molecular-weight heparin (eg. enoxaprin [lovenox]) therapy can indicate heparin-induced thrombocytopenia (HIT), a severe potentially lethal complication. HIT is an immune reaction to heparin-based anticoagulants that causes a drastic decrease in platelet count (ie. < 50% of pretreatment levels and/or platelet count <150,000 and a paradoxical increase in risk for arterial and venous thrombosis (eg. DVT, pulmonary embolism). The nurse should notify the health care provider immediately of decreased platelet levels and anticipate stopping enoxaprin therapy and initiating a non-heparin anticoagulant (eg. rivaroxaban, argatroban)

An elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission laboratory results and identifies which values as the most likely cause of the client's symptoms? A. BNP 70 B. HCT 21% C. Leukocytes 3,500 D. Platelets 105,000

Ans: B HCT is the percentage of RBCs in a volume of whole blood. HCT and Hgb values are related; when one value is decreased, the other is also. This client likely has Hgb of 7. Hgb is a component of the RBC that carries oxygen to the body's tissues. A decrease in Hgb decreases oxygen-carrying capacity and transport to tissues. RBCs may be 100% saturated with oxygen at rest, but desaturation may occur with increased activity and oxygen demand in the presence of decreased HCT and Hgb. Manifestations associated with decreased oxygen transport include SOB with activity, tachypnea, and tachycardia.

The nurse assesses a client 5 minutes after initiating a blood transfusion. The client has shortness of breath, itching, and chills. The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub. What action should the nurse take next? A. Check vital signs B. Maintain IV access with normal saline C. Notify the health care provider D. Recheck identification labels and numbers

Ans: B Signs of a transfusion reaction include chills, fever, low back pain, flushing, and itching. Nursing interventions include: 1. Stop transfusion immediately and disconnect tubing at the catheter hub. 2. Maintain IV access with normal saline, using new tubing to prevent hypotension and vascular collapse. 3. Notify HCP and blood bank 4. Monitor vital signs 5. recheck labels, numbers, and the client's blood type 6. Treat client's symptoms according to the HCP's prescription 7. Collect blood and urine specimens to evaluate for hemolysis 8. Return blood and tubing set to the blood bank for additional testing 9. Complete necessary facility paperwork to document the reaction.

A client is admitted to the medical surgical floor with a hemoglobin level of 5.0 g/dL. The nurse should anticipate which findings?SATA A. course crackles B. Dyspnea C. Pallor D. Respiratory depression E. Tachycardia

Ans: B,C, E A normal hemoglobin level for an adult male is 13.2-17.3 and a female is 11.7-15.5. A client with severe anemia will have tachycardia, which will maintain cardiac output. The cardiovascular system must increase the heart rate and stroke volume to achieve adequate perfusion. Shortness of breath (dyspnea) may occur due to an insufficient number of red blood cells. The respiratory system must increase the respiratory rate to maintain adequate levels of oxygen and carbon dioxide. Pallor (pale complexion) occurs from reduced blood flow to the skin.

Which client finding is most important for the nurse to follow up? A. Client with distinct liver edge even with right costal margin. B. Client with pyelonephritis who has costovertebral angle tenderness. C. Client with rash that has purplish blotches that do not blanche. D. Client with spinal injury whose toes point downward with the Babinski test.

Ans: C Purpura refers to reddish-purple blotches on the skin that do not blanche with pressure due to bleeding underneath the skin. Further assessment must be done to evaluate for a potential serious etiology, such as blood dyscrasia.

Thrombotic thrombocytopenic purpura (TTP) is suspected due to the client's current platelet count of 2,000. Which client sign or symptom is the most concerning and requires immediate further nursing action? A. Current oozing epistaxis B. Ecchymosis on leg since yesterday C. New-onset confusion D. reported history of hematuria

Ans: C TTP consists of hemolytic anemia with fragmentation of erythrocytes, signs of intravascular of hemolysis, thrombocytopenia, decreased renal function, and fever. Regardless of the cause of low platelets, the concern in this case is the critically low platelet count, which puts this client at risk for internal bleeding, especially within the brain. Change in LOC Is the most clinically significant finding requiring an emergency response.

The nurse is caring for a client with severe COPD. The nurse anticipates which lab results for this client? A. anemia B. neutropenia C. Polycythemia D. Thrombocytopenia

Ans: C The client with severe COPD will have a chronically low oxygen level, hypoxemia. To compensate, the body produces more RBCs to carry needed oxygen to the cells. A high RBC count is called polycythemia.

An experienced nurse precepts a graduate nurse caring for a hospitalized client who has a prescription for a transfusion of PRBCs to be hung over 3 hours. Which statement by the graduate nurse indicates the correct rationale for asking the client to void prior to starting the transfusion? A. "A drop in blood pressure is expected during the transfusion and getting up to void may cause a fall." B. "Bedrest is required; therefore, voiding will prevent intermittent catheterization during the procedure." C. "If a transfusion reaction occurs, it will be important to collect a fresh urine specimen to check for hemolyzed RBCs." D. "The urine is collected and analyzed prior to starting the transfusion to assess the client's baseline results."

Ans: C The nurse should ask the client to void or empty the urinary catheter and discard urine prior to starting a blood transfusion. In the event of an acute hemolytic transfusion reaction, a fresh urine specimen should be collected and sent to the laboratory to analyze for hemolyzed RBCs. An acute hemolytic transfusion reaction is a life-threatening reaction in which the host's antibodies rapidly destroy the transfused RBCs and is generally related to incompatibility. Early signs of a hemolytic reaction include red urine, fever, and hypotension; late signs include DIC and hypovolemic shock. The transfusion should be stopped immediately if any sign of transfusion reaction occurs. Starting the transfusion with an empty bladder will help ensure that any urine specimen collected after a reaction is reflective of the body's physiological processes after the blood transfusion has started.

The nurse teaches a client diagnosed with iron-deficiency anemia about iron-rich foods. Which meal does the client choose to indicate that teaching has been effective? A. Chicken salad with lettuce on french bread, chocolate pudding and milk B. Fat-free yogurt, carrot sticks, apple slices, and diet soda C. Ham, steamed carrots, green beans, gelatin desserts, and iced tea D. Kale salad with boiled eggs and dried fruit, a brownie, and orange juice

Ans: D Iron deficiency anemia occurs when the body lacks sufficient iron to form red blood cells and synthesize hemoglobin. Iron-deficiency anemia can result from: 1. Diets low in iron (vegetarian and low-protein diets) 2. Iron not being absorbed (GI surgeries, malabsorption syndromes) 3. Increased iron requirement (growth spurts and breast feeding) 4. Blood loss (menstruation, bleeding in the GI tract [ulcers, hemorrhoids] Foods rich in iron include: -meats -shellfish -eggs, leafy greens, broccoli, dried fruits, beans, brown rice, oatmeal Eating foods rich in vitamin C will enhance iron absorption but coffee and tea consumption interferes with this process.

Which of the following diets would place a client at the highest risk for macrocytic anemia? A. Lacto-ovo-vegetarian B. Lacto-vegetarian C. Macrobiotic D. Vegan

Ans: D Megaloblastic anemia is caused by vitamin B12 or folic acid deficiency. Vitamin B12 deficiency can also result in peripheral neuropathy and cognitive impairment. Vitamin B12 is formed by microorganisms and found only in animal foods; some plant foods may contain minimal amounts of vitamin B12 only if they accidentally contain animal particles. Natural sources of vitamin B12 include meat, fish, poultry, eggs, and milk; some breads and cereals may be fortified with vitamin B12 as well as some nutritional yeasts. Vegans are strict vegetarians; they exclude all animal products , including eggs, milk and milk products from their diet. They also may avoid foods that are processed or not organically grown, thereby eliminating potentially fortified food sources of vitamin b12.

A hospitalized client is receiving chemotherapy. Based on today's blood laboratory results, what action should the nurse take? Lab results: WBC-1,400 Absolute neutrophil count-500 Hemoglobin- 10.5 Platelets-150,000 Serum potassium-3.4 A. Assess for hematuria B. Check for peaked T waves C. Obtain a prescription for epoetin alfa D. Place a mask on the client

Ans: D The normal range for a WBC count is 4,000-11,000. Clients with neutropenia are predisposed to infection. The absolute neutrophil count is determined by multiplying the total WBC count by the percentage of neutrophils. Neutropenia is an absolute neutrophil count below 1,000. An absolute neutrophil count below 500 is defined as severe neutropenia and is a critical emergency. This client's neutropenia is probably a result of bone marrow suppression from the chemotherapy. The client needs reverse or protective isolation from organisms that people or objects may have that the client lacks resistance to. A hospitalized client needs to be in a private room, and the room may need to be equipped with HEPA filtration or positive pressure air flow. Additional neutropenic precautions include avoiding raw fruits/vegetables, standing water, and undercooked meat. In addition, no infectious health care providers should care for the client.

The nurse is caring for a 50-year-old client in the clinic. The client's annual physical examination revealed a hemoglobin value of 10 g/dL (100g/L) compared to 13 g/dL (130 g/L) a year ago. What should the nurse's initial action? A. Encourage intake of over-the-counter iron pills B. Encourage intake of red meat and egg yolks C. Facilitate a screening colonoscopy D. Facilitate another blood test in 6 months

Ans:C Early signs of colorectal cancer are usually nonspecific and include fatigue, weight loss, anemia, and occult gastrointestinal bleeding. Clients should have regular screening colonoscopy for colon cancer starting at age 50 if their risk is average or earlier if their risk is high. Colorectal screening can also include fecal occult blood test or fecal immunochemical test annually. New-onset anemia should be taken seriously at this client's age, and colon cancer must be ruled out. The etiology of anemia must be determined prior to recommending treatment.

Which client is at greatest risk for a PE? A. A client 6-hours post-operative C-section B. A client in Atrial Fibrillation C. A client with subdural hematoma D. A client with pneumonia

Death from pulmonary embolism is often attributed to a missed diagnosis. Early identification of risk factors (eg. venous stasis, hypercoagulability of blood, endothelial damage) can have a positive effect on client outcomes. This postoperative client is at greatest risk due to the presence of the following 4 risk factors. -Abdominal c-section surgery (endothelial damage) -Engorged pelvic vessels from pregnancy (venous stasis, hypercoagulability of blood) -Inactivity/immobility > 6 hours related to positioning during surgery and the immediate postoperative period and epidural anesthesia (venous stasis) -Postpartum state (hypercoagulability of blood).