Chapter 28 Hematologic Function & Treatment Modalities

Through the process of hematopoiesis, stem cells differentiate into either myeloid or lymphoid stem cells. Into what do myeloid stem cells further differentiate? Select all that apply. A. Leukocytes B. Natural killer cells C. Cytokines D. Platelets E. Erythrocytes

A. Leukocytes D. Platelets E. Erythrocytes Rationale: Myeloid stem cells differentiate into three broad cell types: erythrocytes, leukocytes, and platelets. Natural killer cells and cytokines do not originate as myeloid stem cells.

The nurse's brief review of a client's electronic health record indicates that the client regularly undergoes therapeutic phlebotomy. Which of the following rationales for this procedure is most plausible? A. The client may chronically produce excess red blood cells. B. The client may frequently experience a low relative plasma volume. C. The client may have impaired stem cell function. D. The client may previously have undergone bone marrow biopsy.

A. The client may chronically produce excess red blood cells. Rationale: Persistently elevated hematocrit is an indication for therapeutic phlebotomy. It is not used to address excess or deficient plasma volume and is not related to stem cell function. Bone marrow biopsy is not an indication for therapeutic phlebotomy.

A patients electronic health record states that the patient receives regular transfusions of factor IX. The nurse would be justified in suspecting that this patient has what diagnosis? A) Leukemia B) Hemophilia C) Hypoproliferative anemia D) Hodgkins lymphoma

B) Hemophilia Feedback: Administration of clotting factors is used to treat diseases where these factors are absent or insufficient; hemophilia is among the most common of these diseases. Factor IX is not used in the treatment of leukemia, lymphoma, or anemia.

A client has sustained a cut to the hand, immediately initiating the process of hemostasis. Following vasoconstriction, which event in the process of hemostasis will take place? A. Fibrin will be activated at the bleeding site. B. Platelets will aggregate at the injury site. C. Thromboplastin will form a clot. D. Prothrombin will be converted to thrombin.

B. Platelets will aggregate at the injury site. Rationale: Following vasoconstriction, circulating platelets aggregate at the site and adhere to the vessel and to one another, forming an unstable hemostatic plug. Events involved in the clotting cascade take place subsequent to this initial platelet action.

A client is being treated for the effects of a longstanding vitamin B12 deficiency. Which aspect of the client's health history would most likely predispose the client to this deficiency? A. The client has irregular menstrual periods. B. The client is a vegan. C. The client donated blood 60 days ago. D. The client frequently smokes marijuana.

B. The client is a vegan. Rationale: Because vitamin B12 is found only in foods of animal origin, vegans may ingest little vitamin B12. Irregular menstrual periods, marijuana use, and blood donation would not precipitate a vitamin B12 deficiency.

A client has been scheduled for a bone marrow aspiration and admits to the nurse being worried about the pain involved with the procedure. Which statement by the nurse when providing client education would be most accurate? A. "You'll be given painkillers before the test, so there won't likely be any pain." B. "You'll feel some pain when the needle enters your skin, but none during the aspiration." C. "Most people feel some brief, sharp pain when the marrow is aspirated." D. "I'll be there with you, and I'll try to help you keep your mind off the pain."

C. "Most people feel some brief, sharp pain when the marrow is aspirated." Rationale: Clients typically feel a pressure sensation as the needle is advanced into position. The actual aspiration always causes sharp, brief pain, resulting from the suction exerted as the marrow is aspirated into the syringe; the client should be warned about this. Stating, "I'll try to help you keep your mind off the pain" may increase the client's fears of pain, because this does not help the client know what to expect. Although a local anesthetic agent is administered to the skin, subcutaneous tissue, and periosteum of the bone, it is not possible to anesthetize the bone itself, and the client will most likely experience sharp, brief pain during the actual aspiration. Painkillers are not necessarily given before the test and would not likely block all pain from the aspiration.

A client's low hemoglobin level has necessitated transfusion of packed red blood cells. Prior to administration, which action should the nurse perform? A. Have the client identify the blood type in writing. B. Ensure that the client has granted verbal consent for transfusion. C. Assess the client's vital signs to establish baselines. D. Facilitate insertion of a central venous catheter.

C. Assess the client's vital signs to establish baselines. Rationale: Prior to a transfusion, the nurse must take the client's temperature, pulse, respiration, and blood pressure to establish a baseline. Written consent is required, and the client's blood type is determined by type and cross match, not by the client's self-declaration. Peripheral venous access is sufficient for blood transfusion.

Two units of packed red blood cells have been prescribed for a client who has experienced a gastrointestinal bleed. The client is highly reluctant to receive a transfusion, stating, "I'm terrified of getting acquired immunodeficiency syndrome (AIDS) from a blood transfusion." How can the nurse best address the client's concerns? A. "All donated blood is treated with antiretroviral medications before it is used." B. "That did happen in some high-profile cases in the 20th century, but it is no longer a possibility." C. "HIV was eradicated from the blood supply in the early 2000s." D. "Donated blood is screened for human immunodeficiency virus (HIV), and the risk of contraction is very low."

D. "Donated blood is screened for human immunodeficiency virus (HIV), and the risk of contraction is very low." Rationale: The client can be reassured about the very low possibility of contracting HIV from the transfusion. However, it is not an absolute impossibility. Antiretroviral medications are not introduced into donated blood. The blood supply is constantly dynamic, due to the brief life of donated blood.

The nurse is preparing to administer a unit of platelets to an adult client. When administering this blood product, which of the following actions should the nurse perform? A. Administer the platelets as rapidly as the client can tolerate. B. Establish IV access as soon as the platelets arrive from the blood bank. C. Ensure that the client has a patent central venous catheter. D. Aspirate 10 to 15 mL of blood from the client's IV immediately following the transfusion.

A. Administer the platelets as rapidly as the client can tolerate. Rationale: The nurse should infuse each unit of platelets as fast as client can tolerate to diminish platelet clumping during administration. IV access should be established prior to obtaining the platelets from the blood bank. A central line is appropriate for administration, but peripheral IV access (22-gauge or larger) is sufficient. There is no need to aspirate after the transfusion.

A client is scheduled to undergo a bone marrow aspiration. When preparing the client for the procedure, which action would the nurse do first? A. Ensure informed consent has been obtained. B. Cleanse the skin with an antiseptic. C. Administer a local anesthetic. D. Cover the area with a sterile drape.

A. Ensure informed consent has been obtained. Rationale: The first step in the procedure is ensuring that informed consent has been obtained by the health care provider, nurse practitioner, or health care provider assistant performing the procedure and includes the reason the procedure is being performed, alternatives, and risks of the procedure. Risks include infection, bleeding, and pain. After informed consent is obtained, the client is assisted to either a prone or lateral decubitus position. The skin is cleansed using aseptic technique and either a chlorhexidine-based solution or povidone-iodine. A sterile drape is applied, and the skin is numbed using local anesthesia.

A nurse at a blood donation clinic has completed the collection of blood from a client. The client reports feeling "light-headed" and appears pale. Which action by the nurse is most appropriate? A. Help the client to sit, with head lowered below knees. B. Administer supplementary oxygen by nasal prongs. C. Obtain a full set of vital signs. D. Inform a health care provider or other primary care provider.

A. Help the client to sit, with head lowered below knees. Rationale: A donor who appears pale or complains of faintness should immediately lie down or sit with the head lowered below the knees. The client should be observed for another 30 minutes. There is no immediate need for a health care provider's care. Supplementary oxygen may be beneficial, but may take too much time to facilitate before a syncopal episode. Repositioning must precede assessment of vital signs.

A client has been diagnosed with a lymphoid stem cell defect. This client has the potential for a problem involving which of the following? A. Plasma cells B. Neutrophils C. Red blood cells D. Platelets

A. Plasma cells Rationale: A defect in a myeloid stem cell can cause problems with erythrocyte, leukocyte, and platelet production. In contrast, a defect in the lymphoid stem cell can cause problems with T or B lymphocytes, plasma cells (a more differentiated form of B lymphocyte), or natural killer (NK) cells.

A client's most recent blood work reveals low levels of albumin. This assessment finding should suggest the possibility of what nursing diagnosis? A. Risk for imbalanced fluid volume related to low albumin B. Risk for infection related to low albumin C. Ineffective tissue perfusion related to low albumin D. Impaired skin integrity related to low albumin

A. Risk for imbalanced fluid volume related to low albumin Rationale: Albumin is particularly important for the maintenance of fluid balance within the vascular system. Deficiencies nearly always manifest as fluid imbalances. Tissue oxygenation and skin integrity are not normally affected. Low albumin does not constitute a risk for infection.

A client suffers a leg wound which causes minor blood loss. As a result of bleeding, the process of primary hemostasis is activated. What will occur during this process? A. Severed blood vessels constrict. B. Thromboplastin is released. C. Prothrombin is converted to thrombin. D. Fibrin is lysed.

A. Severed blood vessels constrict. Rationale: Primary hemostasis involves the severed vessel constricting and platelets collecting at the injury site. Secondary hemostasis occurs when thromboplastin is released, prothrombin converts to thrombin, and fibrin is lysed.

A client is receiving a blood transfusion and reports a new onset of slight dyspnea. The nurse's rapid assessment reveals bilateral lung crackles and elevated BP. What is the nurse's most appropriate action? A. Slow the infusion rate and monitor the client closely. B. Discontinue the transfusion and begin resuscitation. C. Pause the transfusion and administer a 250 mL bolus of normal saline. D. Discontinue the transfusion and administer a beta-blocker, as prescribed.

A. Slow the infusion rate and monitor the client closely. Rationale: The client is showing early signs of hypervolemia; the nurse should slow the infusion rate and assess the client closely for any signs of exacerbation. At this stage, discontinuing the transfusion is not necessary. A bolus would worsen the client's fluid overload.

An older adult client is exhibiting many of the characteristic signs and symptoms of iron deficiency. In addition to a complete blood count, what diagnostic assessment should the nurse anticipate? A. Stool for occult blood B. Bone marrow biopsy C. Lumbar puncture D. Urinalysis

A. Stool for occult blood Rationale: Iron deficiency in the adult generally indicates blood loss (e.g., from bleeding in the GI tract or heavy menstrual flow). Bleeding in the GI tract can be preliminarily identified by testing stool for the presence of blood. A bone marrow biopsy would not be undertaken for the sole purpose of investigating an iron deficiency. Lumbar puncture and urinalysis would not be clinically relevant.

A nurse has participated in organizing a blood donation drive at a local community center. Which client would most likely be disallowed from donating blood? A. A client who is 81 years of age B. A client whose blood pressure is 78/49 mm Hg C. A client who donated blood 4 months ago D. A client who has type 1 diabetes

B. A client whose blood pressure is 78/49 mm Hg Rationale: For potential blood donors, systolic arterial blood pressure should be 80 to 180 mm Hg, and the diastolic pressure should be 50 to 100 mm Hg. There is no absolute upper age limit. Donation 4 months ago does not preclude safe repeat donation (donors are only required to wait at least 8 weeks between donations), and diabetes is not a contraindication.

The nurse is describing the role of plasminogen in the clotting cascade. Where in the body is plasminogen present? A. Myocardial muscle tissue B. All body fluids C. Cerebral tissue D. Venous and arterial vessel walls

B. All body fluids Rationale: Plasminogen, which is present in all body fluids, circulates with fibrinogen. Plasminogen is found in body fluids, not tissue.

A client's health history reveals daily consumption of two to three bottles of wine. The nurse would consider increased risk for which hematologic disorder when planning assessments and interventions for this client? A. Leukemia B. Anemia C. Thrombocytopenia D. Lymphoma

B. Anemia Rationale: Heavy alcohol use is associated with numerous health problems, including anemia. Leukemia and lymphoma are not associated with alcohol use; Red blood cell levels are typically affected more than platelet levels (i.e., thrombocytopenia).

A client on the medical unit is receiving a unit of packed red blood cells (PRBCs). Difficult intravenous (IV) access has necessitated a slow infusion rate, and the nurse notes that the infusion began 4 hours ago. Which action by the nurse is the most appropriate? A. Apply an icepack to the blood that remains to be infused. B. Discontinue the remainder of the PRBC transfusion, and inform the health care provider. C. Disconnect the bag of PRBCs, cool for 30 minutes, and then administer. D. Administer the remaining PRBCs by the IV direct (IV push) route.

B. Discontinue the remainder of the PRBC transfusion, and inform the health care provider. Rationale: Because of the risk of increased bacterial proliferation in the PRBCs and subsequent infection in the client, a PRBC transfusion should not exceed 4 hours. Remaining blood should not be transfused, even if it is cooled. Blood is not administered by the IV direct route.

A client is receiving the first of two prescribed units of PRBCs. Shortly after the initiation of the transfusion, the client reports chills and experiences a sharp increase in temperature. What is the nurse's priority action? A. Position the client in high Fowler position B. Discontinue the transfusion. C. Auscultate the client's lungs. D. Obtain a blood specimen from the client.

B. Discontinue the transfusion. Rationale: Stopping the transfusion is the first step in any suspected transfusion reaction. This must precede other assessments and interventions, including repositioning, chest auscultation, and collecting specimens.

The nurse is describing normal erythrocyte physiology to a client who has a diagnosis of anemia. The nurse should explain that the erythrocytes consist primarily of which substance? A. Plasminogen B. Hemoglobin C. Hematocrit D. Fibrin

B. Hemoglobin Rationale: Mature erythrocytes consist primarily of hemoglobin, which contains iron and makes up 95% of the cell mass. Erythrocytes are not made of fibrin or plasminogen. Hematocrit is a measure of erythrocyte volume in whole blood.

The nurse is providing care for a 73-year-old client who has a hematologic disorder. Which change in hematologic function is age-related? A. Bone marrow in older adults produces a smaller proportion of healthy, functional blood cells. B. Older adults are less able to increase blood cell production when demand suddenly increases. C. Stem cells in older adults eventually lose their ability to differentiate. D. The ratio of plasma to erythrocytes and lymphocytes increases with age.

B. Older adults are less able to increase blood cell production when demand suddenly increases. Rationale: Due to a variety of factors, when an older person needs more blood cells, the bone marrow may not be able to increase production of these cells adequately. Stem cell activity continues throughout the lifespan, although at a somewhat decreased rate. The proportion of functional cells does not greatly decrease, and the relative volume of plasma does not change significantly.

A client undergoing a hip replacement has autologous blood on standby if a transfusion is needed. What is the primary advantage of autologous transfusions? A. Safe transfusion for clients with a history of transfusion reactions B. Prevention of viral infections from another person's blood C. Avoidance of complications in clients with alloantibodies D. Prevention of alloimmunization

B. Prevention of viral infections from another person's blood. Rationale: The primary advantage of autologous transfusions is the prevention of viral infections from another person's blood. Other secondary advantages include safe transfusion for clients with a history of transfusion reactions, prevention of alloimmunization, and avoidance of complications in clients with alloantibodies.

A client is scheduled for a splenectomy. During discharge education, which teaching point should the nurse prioritize? A. Adhering to prescribed immunosuppressant therapy B. Reporting any signs or symptoms of infection promptly C. Ensuring adequate folate, iron, and vitamin B12 intake D. Limiting activity postoperatively to prevent hemorrhage

B. Reporting any signs or symptoms of infection promptly. Rationale: Clients face an increased risk for infection following splenectomy; therefore, long-term use of antibiotic therapy is indicated. After splenectomy, the client is instructed to seek prompt medical attention if even relatively minor symptoms of infection occur. Often, clients with high platelet counts have even higher counts after splenectomy, which can predispose them to serious thrombotic or hemorrhagic problems. However, this increase is usually transient and therefore often does not warrant additional treatment. Dietary modifications are not normally necessary, and immunosuppressants would be strongly contraindicated.

The nurse caring for a client receiving a transfusion notes that 15 minutes after the infusion of packed red blood cells (PRBCs) has begun, the client is having difficulty breathing and reports severe chest tightness. What is the most appropriate initial action for the nurse to take? A. Notify the client's health care provider. B. Stop the transfusion immediately. C. Remove the client's IV access. D. Assess the client's chest sounds and vital signs.

B. Stop the transfusion immediately. Rationale: Vascular collapse, bronchospasm, laryngeal edema, shock, fever, chills, and jugular vein distension are severe reactions. The nurse should discontinue the transfusion immediately, monitor the client's vital signs, and notify the health care provider. The blood container and tubing should be sent to the blood bank. A blood and urine specimen may be needed if a transfusion reaction or a bacterial infection is suspected. The client's IV access should not be removed.

A client is being treated in the ICU after a medical error resulted in an acute hemolytic transfusion reaction. What was the etiology of this client's adverse reaction? A. Antibodies to donor leukocytes remained in the blood. B. The donor blood was incompatible with that of the client. C. The client had a sensitivity reaction to a plasma protein in the blood. D. The blood was infused too quickly and overwhelmed the client's circulatory system.

B. The donor blood was incompatible with that of the client. Rationale: An acute hemolytic reaction occurs when the donor blood is incompatible with that of the recipient. In the case of a febrile nonhemolytic reaction, antibodies to donor leukocytes remain in the unit of blood or blood component. An allergic reaction is a sensitivity reaction to a plasma protein within the blood component. Hypervolemia does not cause an acute hemolytic reaction.

A client with a hematologic disorder asks the nurse how the body forms blood cells. The nurse understands that this process takes place primarily in which location? A) Spleen B) Kidneys C) Bone marrow D) Liver

C) Bone marrow Rationale: Bone marrow is the primary site for hematopoiesis. The liver and spleen may be involved during embryonic development or when marrow is destroyed. The kidneys release erythropoietin, which stimulates the marrow to increase production of red blood cells. However, blood cells are not primarily formed in the spleen, kidneys, or liver.

A client has come to the OB/GYN clinic due to recent heavy menstrual flow. Because of the client's consequent increase in red cell production, the nurse should recommend the client increase daily intake of what substance? A. Vitamin E B. Vitamin D C. Iron D. Magnesium

C. Iron Rationale: To replace blood loss, the rate of red cell production increases. Iron is incorporated into hemoglobin. Vitamins E and D and magnesium do not need to be increased when RBC production is increased.

Fresh-frozen plasma (FFP) has been prescribed for a hospital client. Prior to administration of this blood product, the nurse should prioritize which client education? A. Infection risks associated with FFP administration B. Physiologic functions of plasma C. Signs and symptoms of a transfusion reaction D. Strategies for managing transfusion-associated anxiety

C. Signs and symptoms of a transfusion reaction Rationale: Clients should be educated about signs and symptoms of transfusion reactions prior to administration of any blood product. In most cases, this is priority over education relating to infection. Anxiety may be an issue for some clients, but transfusion reactions are life-threatening and should be addressed first. Teaching about the functions of plasma is not likely a high priority.

The nurse's review of a client's most recent blood work reveals a significant increase in the number of band cells. The nurse's subsequent assessment should focus on which of the following? A. Respiratory function B. Evidence of decreased tissue perfusion C. Signs and symptoms of infection D. Recent changes in activity tolerance

C. Signs and symptoms of infection Rationale: 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. This finding is not suggestive of problems with oxygenation and subsequent activity intolerance.

Which of the following circumstances would most clearly warrant autologous blood donation? A. The client has type-O blood. B. The client has sickle cell disease or a thalassemia. C. The client has elective surgery pending. D. The client has hepatitis C.

C. The client has elective surgery pending. Rationale: Autologous blood donation is useful for many elective surgeries where the potential need for transfusion is high. Type-O blood, hepatitis, sickle cell disease, and thalassemia are not clear indications for autologous donation.

The nurse is planning the care of a client with a nutritional deficit and a diagnosis of megaloblastic anemia. The nurse should recognize that this client's health problem is due to which issue with the red blood cells (RBCs)? A. Production of inadequate quantities of RBCs B. Premature release of immature RBCs C. Injury to the RBCs in circulation D. Abnormalities in the structure and function of RBCs

D. Abnormalities in the structure and function of RBCs Rationale: Vitamin B12 and folate deficiencies are characterized by the production of abnormally large erythrocytes called megaloblasts. Because these cells are abnormal, many are sequestered (trapped) while still in the bone marrow, and their rate of release is decreased. Some of these cells actually die in the marrow before they can be released into the circulation. This results in megaloblastic anemia. This pathologic process does not involve inadequate production, premature release, or injury to existing RBCs.

A nurse is educating a client about the role of B lymphocytes. The nurse's description will include which of the following physiologic processes? A. Stem cell differentiation B. Cytokine production C. Phagocytosis D. Antibody production

D. Antibody production Rationale: B lymphocytes are capable of differentiating into plasma cells. Plasma cells, in turn, produce antibodies. Cytokines are produced by NK cells. Stem cell differentiation greatly precedes B lymphocyte production.

An interdisciplinary team has been commissioned to create policies and procedures aimed at preventing acute hemolytic transfusion reactions. What action has the greatest potential to reduce the risk of this transfusion reaction? A. Ensure that blood components are never infused at a rate greater than 125 mL/h. B. Administer prophylactic antihistamines prior to all blood transfusions. C. Establish baseline vital signs for all clients receiving transfusions. D. Be vigilant in identifying the client and the blood component.

D. Be vigilant in identifying the client and the blood component. Rationale: The most common causes of acute hemolytic reaction are errors in blood component labeling and client identification that result in the administration of an ABO-incompatible transfusion. Actions to address these causes are necessary in all health care settings. Prophylactic antihistamines are not normally given, and would not prevent acute hemolytic reactions. Similarly, baseline vital signs and slow administration will not prevent this reaction.

The nurse educating a client with anemia is describing the process of red blood cell production. When the client's kidneys sense a low level of oxygen in circulating blood, which physiologic response is initiated? A. Increased stem cell synthesis B. Decreased respiratory rate C. Arterial vasoconstriction D. Increased levels of erythropoietin

D. Increased levels of erythropoietin Rationale: If the kidney detects low levels of oxygen, as occurs when fewer red blood cells are available to bind oxygen (i.e., anemia), erythropoietin levels increase. The body does not compensate with vasoconstriction, decreased respiration, or increased stem cell activity.

A client lives with a diagnosis of sickle cell disease and receives frequent blood transfusions. The nurse should recognize the client's consequent risk of what complication of treatment? A. Hypovolemia B. Vitamin B12 deficiency C. Thrombocytopenia D. Iron overload

D. Iron overload Rationale: Clients with chronic transfusion requirements can quickly acquire more iron than they can use, leading to iron overload. These individuals are not at risk for hypovolemia and there is no consequent risk for low platelet or vitamin B12 levels.

The nurse is caring for a client who has developed scar tissue in many of the areas that normally produce blood cells. What organs can become active in blood cell production by the process of extramedullary hematopoiesis? A. Spleen and kidneys B. Kidneys and pancreas C. Pancreas and liver D. Liver and spleen

D. Liver and spleen Rationale: In adults with disease that causes marrow destruction, fibrosis, or scarring, the liver and spleen can also resume production of blood cells by a process known as extramedullary hematopoiesis. The kidneys and pancreas do not produce blood cells for the body.

A client's wound has begun to heal and the blood clot which formed is no longer necessary. When a blood clot is no longer needed, the fibrinogen and fibrin will be digested by which of the following? A. Plasminogen B. Thrombin C. Prothrombin D. Plasmin

D. Plasmin Rationale: The substance plasminogen is required to lyse (break down) the fibrin. Plasminogen, which is present in all body fluids, circulates with fibrinogen and is therefore incorporated into the fibrin clot as it forms. When the clot is no longer needed (e.g., after an injured blood vessel has healed), the plasminogen is activated to form plasmin. Plasmin digests the fibrinogen and fibrin. Prothrombin is converted to thrombin, which in turn catalyzes the conversion of fibrinogen to fibrin so a clot can form.

A client's diagnosis of atrial fibrillation has prompted the primary care provider to prescribe warfarin. When assessing the therapeutic response to this medication, which action by the nurse is the most appropriate? A. Assess for signs of myelosuppression. B. Review the client's platelet level. C. Assess the client's capillary refill time. D. Review the client's international normalized ratio (INR).

D. Review the client's international normalized ratio (INR). Rationale: The INR and activated partial thromboplastin time serve as useful tools for evaluating a client's clotting ability and monitoring the therapeutic effectiveness of anticoagulant medications. The client's platelet level is not normally used as a short-term indicator of anticoagulation effectiveness. Assessing the client for signs of myelosuppression and assessing capillary refill time do not address the effectiveness of anticoagulants.

A nurse is caring for a client who is undergoing preliminary testing for a hematologic disorder. Which sign or symptom of a hematologic disorder is most common? A. Sudden change in level of consciousness (LOC) B. Recurrent infections C. Anaphylaxis D. Severe fatigue

D. Severe fatigue Rationale: The most common indicator of hematologic disease is extreme fatigue. This is more common than changes in LOC, infections, or anaphylaxis.