Hemat. & Lymph. System (2 of 3)
A client is being treated in the hospital for hypovolemia related to a bleeding peptic ulcer. The nurse obtains a blood pressure reading of 88/62 mm Hg, heart rate of 112 beats/minute, and a respiratory rate of 24 breaths/minute. What is the first action by the nurse?
Notify the physician.
The nurse is caring for four clients on the medical-surgical unit of the hospital. What client is mostly likely to be receiving treatment for sickle cell crisis?
A 19-year-old African American male
The registered nurse (RN) and licensed practical nurse (LPN) are preparing an educational program for clients who may be at risk for the development of iron-deficiency anemia. Which clients would receive the greatest benefit from this program? Select all that apply.
A young female client with bulimia nervosa An older adult client on a fixed income A client with Crohn's disease
A client has just been admitted to the unit with a diagnosis of Hodgkin's disease. When doing the initial assessment, what pertinent questions should the nurse ask the client to help determine the correct nursing diagnosis?
Are you experiencing fever, chills, or night sweats?
A client is found to have a low hemoglobin and hematocrit when laboratory work was performed. What does the nurse understand the anemia may have resulted from? Select all that apply.
Blood loss Abnormal erythrocyte production Destruction of normally formed red blood cells
The nurse is admitting a client with Cooley's anemia to the hospital with a hemoglobin of 6.2 g/dL and hematocrit of 26%. What does the nurse document about the client's skin?
Bronzing of the skin
The nursing instructor is talking with her clinical group about coagulopathies. How should the instructor define coagulopathies?
Coagulopathies are bleeding disorders that involve platelets or clotting factors.
A client diagnosed with polycythemia vera has come into the clinic because he has developed a nighttime cough, fatigue, and shortness of breath. From these clinical manifestations, what complication would the nurse suspect in this client?
Congestive heart failure
The nurse is instructing the client with polycythemia vera how to perform isometric exercises such as contracting and relaxing the quadriceps and gluteal muscle during periods of inactivity. What does the nurse understand is the rationale for this type of exercise?
Contraction of skeletal muscle compresses the walls of veins and increases the circulation of venous blood as it returns to the heart.
The nurse is instructing a client about taking a liquid iron preparation for the treatment of iron-deficiency anemia. What should the nurse include in the instructions?
Dilute the liquid preparation with another liquid such as juice and drink with a straw.
An adult client has developed lymphedema postmastectomy. What is the common method used to promote lymphatic drainage and prevent edema in all clients with lymphedema?
Elevate the affected part of the body.
The nurse is performing a physical assessment on a client with a suspected lymphatic disorder. What would be the nurse's primary assessment for all clients with lymphatic disorders?
Enlargement of the lymph glands
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 client with lymphadenitis has developed persistent swelling of the affected area. What would be important information for the nurse to teach this client?
How to apply an elastic sleeve or stocking
A client was admitted to the hospital with a pathologic pelvic fracture. The client informs the nurse that he has been having a strange pain in the pelvic area for a couple of weeks that was getting worse with activity prior to the fracture. What does the nurse suspect may be occurring based on these symptoms?
Multiple myeloma
The nurse is caring for an older adult client who has hemoglobin of 9.6 g/dL and a hematocrit of 34%. To determine where the blood loss is coming from, what intervention can the nurse provide?
Observe stools for blood.
The client is receiving chemotherapy for a diagnosis of lymphosarcoma. The client experiences nausea. What measures should the nurse suggest to help the client reduce the feeling of nausea?
Offer clear liquids such as carbonated beverages, water, and ice pops.
The nurse is caring for a client with multiple myeloma. Why would it be important to assess this client for fractures?
Osteoclasts break down bone cells so pathologic fractures occur.
The nurse is caring for a client who is developing hypovolemic shock from a duodenal ulcer bleed. What is the first intervention the nurse can provide to facilitate blood flow to the brain?
Place the client in a modified Trendelenburg position.
A client is experiencing chronic hypovolemic anemia as evidenced by laboratory results. What symptoms does the nurse expect to find for this client when collecting objective data?
Postural hypotension
The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. What is the rationale for this statement by the nurse?
Trauma and microabrasions from a non-electric razor may contribute to anemia.
The nurse is caring for a client with hypovolemic anemia who is now in hypovolemic shock. What indication does the nurse have that the client is having inadequate renal perfusion?
Urine output of 15 mL/hr
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.
A client with sickle cell disease informs the nurse that he is having chest pain. The nurse hears the client coughing, wheezing, and breathing rapidly. What does the nurse suspect is occurring with this client?
acute chest syndrome
A client comes to the walk-in clinic complaining of weakness and fatigue. While assessing this client, the nurse finds evidence of petechiae and ecchymoses. The nurse notes that the spleen appears enlarged. What would the nurse suspect is wrong with this client?
aplastic anemia
A teenaged client with hemophilia sustains a leg laceration after falling off of his skateboard and is brought to the emergency department. The laceration is bleeding profusely even with direct pressure to the site. What does the nurse anticipate will be ordered for administration to control bleeding?
fresh frozen plasma
The nurse is instructing the client with sickle cell disease about the use of an inhaled vasodilator that may reduce sickling. What medication is the nurse instructing the client about?
nitric oxide
The nurse is assisting the client with multiple myeloma to ambulate. What is the most important nursing diagnosis to help prevent fractures in this client?
safety
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."
The nurse is assigned to care for a client with polycythemia vera. When the nurse encourages the client to drink 3 L of fluid per day, the client states, "Why do I have to drink so much?" What is the best response by the nurse?
"It helps adequately hydrate you and ensures a sufficient urine production."
Parents arrive to the clinic with their young child and inform the nurse the child has just been diagnosed with sickle cell disease. The parents ask the nurse how this could have happened and which one of them is the carrier. What is the best response by the nurse?
"The child must inherit two defective genes, one from each parent."
The LPN is following a plan of care for a client who is being treated for hypovolemic anemia and is at risk for hypovolemic shock. The nurse assesses vital signs and O2 saturation and observes the saturation at 89% for 3 minutes. What should the first action by the nurse be?
Give oxygen per nasal cannula
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.
The nursing instructor is discussing disorders of the hematopoietic system with the pre-nursing pathophysiology class. What disease would the instructor list with a primary characteristic of erythrocytosis?
polycythemia vera
A client is suspected of having leukemia and is having a series of laboratory and diagnostic studies performed. What does the nurse recognize as the hallmark signs of leukemia? Select all that apply.
Frequent infections Fatigue from anemia Easy bruising
The nurse is caring for an older adult client who has been admitted to the unit with anemia. What would the nurse expect the client to possibly exhibit?
Blood loss from the gastrointestinal or genitourinary tract
