LWW: Immune & Hematology
Which action takes priority for a client who is experiencing a hypersensitivity reaction to latex?
Administering supplemental oxygen Explanation: Airway, breathing, and circulation always take top priority.
A client's blood studies reveal a deficiency in all of the blood's formed elements. The physician suspects that the client's bone marrow is failing to generate enough new cells. Which disorder is most likely affecting this client?
Aplastic anemia
A client's blood studies reveal a deficiency in all of the blood's formed elements. The physician suspects that the client's bone marrow is failing to generate enough new cells. Which disorder is most likely affecting this client?
Aplastic anemia usually results from injury or destruction of stem cells in bone marrow or the bone marrow matrix, causing pancytopenia (anemia, granulocytopenia, and thrombocytopenia) and bone marrow hypoplasia (fatty bone marrow).
A nurse is reinforcing discharge instructions for a client with systemic lupus erythematosus (SLE). Which intervention is most important for the nurse to include?
Clients with SLE have photosensitivity to sunlight and should wear SPF 15 or higher sunscreen daily, protective clothing, and/or avoid sun exposure to limit photosensitive rash or disease flares.
The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site. What do these signs suggest?
Infection
A client was admitted with a platelet count of 95,000/µl (95 × 109/L). What would the nurse anticipate observing during data collection?
The normal thrombocytes (platelet) count is 150,000/µl (150 × 109/L) to 400,000/µl (400 × 109/L). The client has thrombocytopenia or low platelet count. Platelets are necessary for clot formation, so petechiae and bruising are signs of a decreased number of platelets. Weakness and fatigue are signs of anemia.
A pregnant woman arrives at the emergency department with abruptio placentae at 34 weeks gestation. Which blood dyscrasia should the nurse closely monitor for?
disseminated intravascular coagulation (DIC) Explanation: Abruptio placentae is a cause of DIC because of activation of the clotting cascade after hemorrhage.
A nurse is caring for a client who had cardiac revascularization surgery 3 days ago. Upon analysis of lab reports, the nurse notes the client's platelet count decreased from 230,000 to 5,000 uL? Which condition is suspected?
heparin-associated thrombosis and thrombocytopenia (HATT)
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. What should the nurse instruct the client to do?
sit upright, leaning slightly forward
A client is receiving the drug epoetin alfa. Which findings would indicate the effectiveness of the drug?
susceptibility to infection
A child is seeing the health care provider for bone and joint pain. Which other signs and symptoms may suggest leukemia?
petechiae Explanation: The most common signs and symptoms of leukemia result from infiltration of the bone marrow. These include petechiae, fever, pallor, and joint pain with decreased activity level.
A client with pernicious anemia is receiving parenteral vitamin B12 therapy. Which client statement indicates effective teaching about this therapy?
"I will receive parenteral vitamin B12 therapy for the rest of my life." Explanation: Because a client with pernicious anemia lacks intrinsic factor, oral vitamin B12 can't be absorbed. Therefore, parenteral vitamin B12 therapy is recommended and required for life.
A nurse is reinforcing the education plan with the parent of a 12-year-old child recently diagnosed with systemic juvenile arthritis (JA). Which statements by the parent best indicate that education has been effective?
"Maintaining an appropriate, regular exercise program is very important." "It's important that my child's diet includes 1,300 mg of calcium daily." "Warm showers in the morning may be very beneficial to easing my child's morning discomforts."
A child tests positive for the sickle cell trait, and the parents ask the nurse what this means. Which response by the nurse would be most appropriate?
A child with sickle cell trait is only a carrier and may never show any symptoms, except under special hypoxic conditions. A child with sickle cell trait doesn't have the disease and will never test positive for sickle cell anemia.
Which nursing intervention takes priority for a client infected with Pneumocystis carinii pneu
Auscultating breath sounds Explanation: Auscultating breath sounds takes priority for the client admitted with P. carinii pneumonia. Clients with this complication may suffer a rapid deterioration in respiratory status;
The nurse is caring for a client diagnosed with chronic thrombocytopenia. Before discharge, the nurse reinforces which activities to the client to decrease excessive bleeding? Select all that apply.
Avoid alcohol. Avoid aspirin and ibuprofen. Check with your health care provider about taking OTC drugs. Explanation: Alcohol slows the production of platelets. Two medicines that may affect platelets and raise the risk of bleeding are aspirin and ibuprofen.
A client receiving antiplatelet therapy is being monitored for adverse reactions. For which most commonly produced adverse reaction would the nurse observe this client?
Clients receiving antiplatelet agents usually develop bleeding due to the decrease responsiveness of platelets to clot.
A client has been taking a decongestant for allergic rhinitis. During a follow-up visit, which data collected by the nurse suggests that the decongestant has been effective?
Decongestants relieve congestion and sneezing and reduce labored respirations. When effective, decongestants dry the mucous membranes; therefore, nasal drainage should be decreased, and the client should not experience tearing.
A pregnant woman has recently found out she is positive for the human immunodeficiency virus (HIV). When discussing the impact of the condition and care of the infant what information should be provided? Select all that apply.
Definitively diagnosing a newborn with HIV is challenging in the first year of life. Taking the prescribed antiviral medications during the pregnancy will significantly lower the risk of HIV transmission to the baby. Explanation: A confirmed diagnosis is difficult during the first 15 months of life because of the presence of maternal antibody. Symptoms may present prior to 1 year of age in an infected newborn. The use of antiviral therapies in an HIV pregnant woman can reduce transmission to the newborn to less than 1%. The recommended method of birth is cesarean section. Breast-feeding is not recommended for women who are HIV positive.
A nurse is reinforcing nutritional counseling to the parent of a child with celiac disease. Which statement by the parent indicates understanding of the diet?
I need to read food labels carefully to avoid gluten additives in foods."
A 1-year-old infant is pale, but the physical examination is normal. Blood studies reveal a hematocrit of 24% (0.24). Which question by the nurse to the parents would be most useful in helping to establish a diagnosis of anemia?
Iron deficiency anemia is the most common nutritional deficiency in infants between ages 9 months and 15 months. Anemia in a 1-year-old is mostly nutritional in origin, and its cause will be suggested by a detailed nutritional history.
The parents of a child diagnosed with leukemia have stated that they'll give aspirin to their child for pain relief. Which statement by the nurse about aspirin would be most accurate?
It's contraindicated because it promotes bleeding tendencies."
Question 1 of 20 A client with allergic rhinitis is prescribed loratadine. On a follow-up visit, the client tells the nurse, "I take one 10-mg tablet of Claritin with a glass of water two times daily." The nurse concludes that the client requires additional teaching about this medication because:
Loratadine is taken once daily
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?
Lymphangiography may turn the urine blue temporarily; it doesn't alter stool color. For several months after the procedure, the upper part of the feet may appear blue, not red.
For a client with an exacerbation of rheumatoid arthritis, the physician prescribes the corticosteroid prednisone. When caring for this client, the nurse should monitor for which adverse drug reactions?
Prednisone can cause a wide range of adverse reactions, including increased weight caused by fluid retention, hypertension, insomnia, ecchymoses, suppressed inflammation, behavioral changes, and myopathy.
The nurse is caring for a child experiencing a sickle cell crisis. What priority nursing intervention should the nurse perform?
Priority care for a child in a sickle cell crisis includes providing hydration and oxygenation to prevent more sickling.
Two days after a client undergoes splenectomy, a nurse changes his abdominal dressings according to the physician's order. How should the nurse proceed with the dressing change? You Selected:
Remove the soiled dressings using clean gloves.
Which findings should the nurse expect when collecting data on a client admitted in sickle cell crisis?
Signs and symptoms include acute pain, pale skin, tachycardia and tachypnea, swelling in the extremities, fever, infection, neurological changes, fatigue, and jaundice.
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
Sitting upright and leaning slightly forward avoids increasing vascular pressure in the nose and helps the client avoid aspirating blood. L
A nurse obtains data from a client receiving a blood transfusion and determines that the client is wheezing, has chills, and back pain. What is the priority action of the nurse?
Stop the transfusion
A client was admitted with human immunodeficiency virus (HIV). Which statement by the client would indicate the need for further education regarding safer sex practices?
Water-based lubricants should be used; oil- or petroleum-based products can damage latex condoms.. Checking for damaged, defective, or expired condoms ensures the integrity of the condoms and decreases the likelihood of HIV transmission.
The nurse is caring for a client with pernicious anemia. Which question by the nurse explains the potential source of the anemia?
What type of diet do you follow?" Explanation: The use of a vegan diet can lead to pernicious anemia from not eating foods such as meat, poultry, shellfish, eggs, and dairy products that maintain B12 levels.
The nurse is caring for a teen diagnosed with acute lymphocytic leukemia (ALL). A review of the laboratory report indicates a platelet count of 125,500/?L. When gathering data, which finding is most consistent with this laboratory result?
bruising Explanation: Platelet production may be impaired in the client with leukemia. A platelet count of 125,000/?L is less than normal. This may be accompanied with bruising or reports of nosebleeds.
While gathering data about a child's skin integrity, the nurse observes a papular pruritic rash with some vesicles. The rash is profuse on the trunk and sparse on the distal limbs. What does the nurse correlate this finding with?
chickenpox
A client with human immunodeficiency virus (HIV) experiences frequent bouts of diarrhea. The nurse determines dietary teaching is effective when the client states which food to avoid?
milk Explanation: Clients with chronic diarrhea may develop intolerance to lactose, which may worsen the diarrhea
The nurse is reinforcing nutritional information with a client with a leukocyte (WBC) count of 2,500/µL (2.50 × 109/L). What food should the nurse be sure to have the client avoid?
raw carrot sticks Explanation: The normal leukocyte (WBC) is 4.500 /(4.50 × 109/L) to 11,000/ (11.00 × 109/L). A WBC count of 2,500/ (2.50 × 109/L) is low, making the client prone to infection. A low-bacteria diet is indicated, which excludes raw fruits and vegetables.
Which clinical manifestations should a nurse expect to see in a child in stage V of Reye syndrome?
seizures, flaccidity, and respiratory arrest
A nurse is caring for a client newly diagnosed with Human Immunodeficiency Virus (HIV). Which action by the nurse violates the client's confidentiality?
sharing the client's information with the clergy who is visiting with the client
The nurse is meeting with a client who has recently been diagnosed with human immunodeficiency virus (HIV). The client is concerned about the impact of sharing the recent diagnosis with friends and family. What information can the nurse provide to the client?
sharing the diagnosis with friends and family members will provide a needed source of support
A client is admitted with a serum potassium level of 6.5 mEq/L (6.5 mmol/L). Which medication should the nurse anticipate to administer?
sodium polystyrene sulfonate Explanation: The client has an elevated serum potassium level. The normal serum potassium level is 3.5 to 5.3 mEq/L (3.5 to 5.3 mmol/L). Sodium polystyrene sulfonate is used to lower serum potassium in clients with hyperkalemia.
The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instructions should the nurse include in the teaching plan? Select all that apply.
stay out of direct sunlight monitor body temperature taper steroid treatment
Which statement by a client with sickle cell disease indicates further education is needed to reinforce the therapeutic regimen?
"I should take one baby aspirin daily to help prevent sickle cell crisis." Explanation: Aspirin inhibits platelet aggregation and won't help prevent sickle cell crisis.
The nurse is caring for a client with multiple myeloma. Which condition should the client be closely monitored for?
Calcium is released when bone is destroyed. This causes an increase in serum calcium levels. Multiple myeloma doesn't affect potassium, sodium, or magnesium levels.
Which aspect is most important for successful management of the child with Reye syndrome?
Early diagnosis and therapy are essential because of the rapid, clinical course of the disease and its high mortality
The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?
Fever can signal an exacerbation and should be reported to the physician.
A nurse has instructed a client about taking ferrous sulfate liquid preparation. Which statement by the client indicates the need for additional education?
I should take the iron with an antacid to prevent gastric distress." Explanation: Antacids will interfere with absorption of iron and should be avoided.
A nurse is caring for a cleint with non-Hodgkin's lymphoma. Which statement indicates that the client diagnosed with non-Hodgkin's lymphoma needs further reinforcement from the education plan?
If I stay healthy and eat right, I can cure this disease." Explanation: Non-Hodgkin's lymphoma cannot be cured by staying healthy.
A child is admitted to the hospital for an asthma exacerbation. The nursing history reveals this client was exposed to chickenpox 1 week ago. When would this client require isolation if he or she were to remain hospitalized?
Immediate isolation is required Explanation: The incubation period for chickenpox is 2 to 3 weeks, commonly 13 to 17 days. A client is commonly isolated 1 week after exposure to avoid the risk of an earlier breakout. A person is infectious from 1 day before eruption of lesions until after the vesicles have formed crusts.
How can a nurse best ensure the safety of a client who has a latex allergy?
Make sure that the latex allergy is properly documented.
A child with pauciarticular juvenile rheumatoid arthritis (JRA) is being seen for an annual physical examination. The child's parent reports not understanding why the child will need to have an annual eye examination if there are no visual problems. Which statement by the nurse is mostappropriate?
Painless iritis (inflammation of the iris) is commonly seen with the disease."
A multidisciplinary oncology team of physicians, nurses, and the social worker notes that a client who has been undergoing chemotherapy is now experiencing pancytopenia. When reviewing the laboratory data, which values support this diagnosis.
Pancytopenia is a deficiency of all blood cells which includes a state of leukopenia (decreased white blood cells), thrombocytopenia (decreased platelets)and anemia, (decreased red blood cells)
The nurse is obtaining a dietary history from a newly admitted client. Which food eaten by the client does the nurse recognize is a common allergen?
Strawberries: Common food allergens include berries, peanuts, Brazil nuts, cashew nuts, shellfish, and eggs. Bread, carrots, and oranges rarely cause allergic reactions.
The nurse is reinforcing teaching instructions to a client with trigeminal neuralgia on how to minimize pain episodes. Which comments by the client would indicate correct understanding of instructions? Select all that apply.
The facial pain of trigeminal neuralgia is triggered by mechanical or thermal stimuli. Chewing food on the unaffected side and rinsing the mouth rather than brushing teeth reduce mechanical stimulation. Drinking fluids at room temperature reduces thermal stimulation. Eating hot or cold food and washing the face with cold water are likely to trigger pain.
Which nursing action is most important to decrease the risk of postoperative complications in a child with sickle cell anemia?
The main surgical risk from anesthesia is hypoxia; however, emotional stress, demands of wound healing, and the potential for infection can each increase the sickling phenomenon. Increased fluids are encouraged because keeping the child well-hydrated is most important for hemodilution to prevent sickling.
Two days after a client undergoes splenectomy, a nurse changes his abdominal dressings according to the physician's order. How should the nurse proceed with the dressing
The nurse should put on clean gloves to remove the soiled dressings. If contamination with body fluids is likely, the nurse should also put on a gown and face shield. The nurse should dispose of the soiled dressings in a receptacle designated for infectious wastes. The nurse should dispose of the soiled gloves and put on a pair of sterile gloves to place sterile dressings over the incision, according to aseptic technique.
Which symptom is the most common manifestation of severe combined immunodeficiency disease (SCID)?
susceptibility to infection
The nurse is caring for a child who is receiving steroid therapy as a part of the cancer treatment plan. The child tearfully asks the nurse," Why does my face looks so "fat?" What information should be included in the nurse's response?
This change is temporary and will subside once the steroid medication has been discontinued.
The client is starting the first chemotherapy treatment after a diagnosis of lymphoma. What priority nursing action can be delegated to the LPN?
completing vital signs Explanation: The LPN can check vital signs prior to chemotherapy.
A client is injected with radiographic contrast medium and immediately shows signs of dyspnea, flushing, and pruritus. Which intervention should take priority?
make sure the airway is patent
How can a nurse best protect herself after she experiences a minor allergic reaction to latex?
After experiencing a latex allergy of any magnitude, the nurse must protect herself by avoiding all latex products.
The physician orders tests to determine if a client has systemic lupus erythematosus (SLE). Which test result confirms SLE?
An above-normal anti-deoxyribonucleic acid (DNA) test
The nurse is collecting data on a client who has been experiencing black stools for the past month. The client suddenly reports chest and stomach pain. Which action should the nurse perform first
take vital signs Explanation: The first step of nursing process is data collection. Taking vital signs would determine hemodynamic stability, and monitoring heart rhythm may be indicated based on data collected.
A client in a late stage of acquired immunodeficiency syndrome (AIDS) shows signs of AIDS-related dementia. Which nursing diagnosis takes highest priority?
In a client with AIDS, deterioration of the central nervous system (CNS) can lead to AIDS-related dementia. This type of dementia impairs cognition and judgment, placing the client at risk for injury.
Which instruction would be appropriate for the nurse to reinforce during education with a client who has human immunodeficiency virus (HIV) and is at high risk for altered oral mucous membranes?
Lubricating the lips will keep them moist and prevent cracking. A firm toothbrush would damage already sensitive gums. An astringent would be painful, as would foods that are too hot.
The nurse is working in the emergency department when a child is admitted in sickle cell crisis. Which intervention should the nurse expect to perform?
The primary therapy for sickle cell crisis is to increase fluid intake (according to age) and to give analgesics.
The nurse is reinforcing education to the parents of a child with leukemia about the three main consequences. What should the nurse inform the parents they should monitor for?
The three main consequences of leukemia are anemia, caused by decreased erythrocyte production; infection secondary to neutropenia; and bleeding tendencies from decreased platelet production.
A client with acquired immunodeficiency syndrome (AIDS) is prescribed zidovudine (azidothymidine, AZT), 200 mg by mouth every 4 hours. When teaching the client about this drug, the nurse should provide which instruction?
To be effective, zidovudine must be taken exactly as prescribed. Food doesn't affect absorption of this drug, so the client may take zidovudine either with food or on an empty stomach. To avoid serious drug interactions, the client should check with the physician before taking OTC medications.
Which type of leukemia with fast growing immature lymphocytes accounts for most cases of childhood leukemia?
acute lymphocytic leukemia (ALL) Explanation: The most common subtype, ALL, accounts for 75% to 80% of all childhood cases
