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Chapter 31 Nursing Management: Hematologic Problems 121 7. A 20-year-old female patient is in the emergency department for anorexia and fatigue. She takes phenytoin (Dilantin)
for a seizure disorder and oral contraceptives. Which type of anemia is this patient most at risk for?
a. Aplastic anemia c. Iron-deficiency anemia
b. Hemolytic anemia d. Folic acid deficiency anemia
8. Explain the following laboratory findings in anemia.
Finding Explanation
Reticulocyte counts are increased in chronic blood loss but decreased in cobalamin (vitamin B12) deficiency.
Bilirubin levels are increased in sickle cell anemia but are normal in acute blood loss.
Mean corpuscular volume (MCV) is increased in folic acid deficiency but decreased in iron-deficiency anemia.
9. When teaching the patient about a new prescription for oral iron supplements, what does the nurse instruct the patient to do?
a. Increase fluid and dietary fiber intake b. Take the iron preparations with meals
c. Use enteric-coated preparations taken with orange juice d. Report the presence of black stools to the health care provider
10. In teaching the patient with pernicious anemia about the disease, the nurse explains that it results from a lack of
a. folic acid. c. extrinsic factor.
b. intrinsic factor. d. cobalamin intake.
11. During the assessment of a patient with cobalamin deficiency, what manifestation would the nurse expect to find in the patient?
a. Icteric sclera c. Paresthesia of the hands and feet
b. Hepatomegaly d. Intermittent heartburn with acid reflux
12. The nurse determines that teaching about pernicious anemia has been effective when the patient says a. “This condition can kill me unless I take injections of the vitamin for the rest of my life.”
b. “My symptoms can be completely reversed if I take cobalamin (vitamin B12) supplements.”
c. “If my anemia does not respond to cobalamin therapy, my only other alternative is a bone marrow transplant.”
d. “The least expensive and most convenient treatment of pernicious anemia is to use a diet with foods high in cobalamin.”
13. The strict vegetarian is at highest risk for the development of which anemia?
a. Thalassemia c. Folic acid deficiency anemia
b. Iron-deficiency anemia d. Cobalamin deficiency anemia
14. A patient with aplastic anemia has a nursing diagnosis of impaired oral mucous membrane. The etiology of this diagnosis can be related to the effects of what deficiencies (select all that apply)?
a. RBCs d. Coagulation factor VIII
b. Ferritin e. White blood cells (WBCs)
c. Platelets
15. Nursing interventions for the patient with aplastic anemia are directed toward the prevention of which complications?
a. Fatigue and dyspnea c. Thromboemboli and gangrene
b. Hemorrhage and infection d. Cardiac dysrhythmias and heart failure
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16. Which statements describe anemia related to blood loss (select all that apply)?
a. A major concern is prevention of shock.
b. This anemia is most frequently treated with increased dietary iron intake.
c. In addition to the general symptoms of anemia, this patient also manifests jaundice.
d. Clinical symptoms are the most reliable way to evaluate the effect and degree of blood loss.
e. A patient who has acute blood loss may have postural hypotension and increased heart rate.
17. What causes the anemia of sickle cell disease?
a. Intracellular hemolysis of sickled RBCs c. Autoimmune antibody destruction of RBCs b. Accelerated breakdown of abnormal RBCs d. Isoimmune antibody-antigen reactions with RBCs 18. A patient with sickle cell anemia asks the nurse why the sickling crisis does not stop when oxygen therapy is started.
Which explanation should the nurse give to the patient?
a. Sickling occurs in response to decreased blood viscosity, which is not affected by oxygen therapy.
b. When RBCs sickle, they occlude small vessels, which causes more local hypoxia and more sickling.
c. The primary problem during a sickle cell crisis is destruction of the abnormal cells, resulting in fewer RBCs to carry oxygen.
d. Oxygen therapy does not alter the shape of the abnormal erythrocytes but only allows for increased oxygen concentration in hemoglobin.
19. What is a nursing intervention that is indicated for the patient during a sickle cell crisis?
a. Frequent ambulation
b. Application of antiembolism hose c. Restriction of sodium and oral fluids
d. Administration of large doses of continuous opioid analgesics
20. During discharge teaching of a patient with newly diagnosed sickle cell disease, what should the nurse teach the patient to do?
a. Limit fluid intake b. Avoid humid weather
c. Eliminate exercise from the lifestyle
d. Seek early medical intervention for upper respiratory infections
21. Which statements accurately describe thrombocytopenia (select all that apply)?
a. Patients with platelet deficiencies can have internal or external hemorrhage.
b. The most common acquired thrombocytopenia is thrombotic thrombocytopenic purpura (TTP).
c. Immune thrombocytopenic purpura (ITP) is characterized by increased platelet destruction by the spleen.
d. TTP is characterized by decreased platelets, decreased RBCs, and enhanced aggregation of platelets.
e. A classic clinical manifestation of thrombocytopenia that the nurse would expect to find on physical examination of the patient is ecchymosis.
22. A 45-year-old patient has symptoms including arthralgia, impotence, weight loss, and liver enlargement. His laboratory results include an elevated serum iron, total iron binding capacity (TIBC), and serum ferritin levels.
Which disorder does this describe and which treatment will be used?
a. Thalassemia; combination chemotherapy c. Myelodysplastic syndrome; filgrastim (Neupogen) b. Hemochromatosis; deferoxamine (Desferal) d. Delayed transfusion reaction; deferasirox (Exjade) 23. In providing care for a patient hospitalized with an acute exacerbation of polycythemia vera, the nurse gives priority
to which activity?
a. Maintaining protective isolation c. Protecting the patient from injury or falls
b. Promoting leg exercises and ambulation d. Promoting hydration with a large oral fluid intake 24. A patient has a platelet count of 50,000/µL and is diagnosed with ITP. What does the nurse anticipate that initial
treatment will include?
a. Splenectomy c. Administration of platelets
b. Corticosteroids d. Immunosuppressive therapy
Chapter 31 Nursing Management: Hematologic Problems 123 25. Priority Decision: A patient is admitted to the hospital for evaluation and treatment of thrombocytopenia. Which
action is most important for the nurse to implement?
a. Taking the temperature every 4 hours to assess for fever b. Maintaining the patient on strict bed rest to prevent injury c. Monitoring the patient for headaches, vertigo, or confusion
d. Removing the oral crusting and scabs with a soft brush four times a day
26. The nurse caring for a patient with heparin-induced thrombocytopenia (HIT) identifies risk for bleeding as the priority nursing diagnosis. Identify at least five nursing interventions that should be implemented.
a.
b.
c.
d.
e.
27. In reviewing the laboratory results of a patient with hemophilia A, what would the nurse expect to find?
a. An absence of factor IX c. A prolonged bleeding time
b. A decreased platelet count d. A prolonged partial thromboplastin time (PTT)
28. A patient with hemophilia comes to the clinic for treatment. What should the nurse anticipate that he or she will need to administer?
a. Whole blood c. Factor concentrates
b. Thromboplastin d. Fresh frozen plasma
29. A patient with hemophilia is hospitalized with acute knee pain and swelling. What is an appropriate nursing intervention for the patient?
a. Wrapping the knee with an elastic bandage
b. Placing the patient on bed rest and applying ice to the joint
c. Administering nonsteroidal antiinflammatory drugs (NSAIDs) as needed for pain d. Gently performing range-of-motion (ROM) exercises to the knee to prevent adhesions
30. Which bleeding disorder affects both genders, is autosomal dominant, and will have laboratory results showing prolonged bleeding time?
a. Hemophilia A c. Thrombocytopenia
b. Hemophilia B d. von Willebrand disease
31. Number in sequence the events that occur in disseminated intravascular coagulation (DIC).
a. Activation of fibrinolytic system b. Uncompensated hemorrhage
c. Widespread fibrin and platelet deposition in capillaries and arterioles d. Release of fibrin-split products
e. Fibrinogen converted to fibrin f. Inhibition of normal blood clotting g. Production of intravascular thrombin
h. Depletion of platelets and coagulation factors
32. A patient has a WBC count of 2300/µL and a neutrophil percentage of 40%.
a. Does the patient have leukopenia?
b. What is the patient’s neutrophil count?
c. Does the patient have neutropenia?
d. Is the patient at risk for developing a bacterial infection? If so, why?
33. What is the most important method for identifying the presence of infection in a neutropenic patient?
a. Frequent temperature monitoring c. Assessing for redness and swelling b. Routine blood and sputum cultures d. Monitoring white blood cell (WBC) count
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34. What is a major method of preventing infection in the patient with neutropenia?
a. Prophylactic antibiotics
b. A diet that eliminates fresh fruits and vegetables c. High-efficiency particulate air (HEPA) filtration rooms d. Strict hand washing by all persons in contact with the patient
35. How does myelodysplastic syndrome (MDS) differ from acute leukemias?
a. MDS has a slower disease progression.
b. MDS does not result in bone marrow failure.
c. MDS is a clonal disorder of hematopoietic cells.
d. MDS affects only the production and function of platelets and WBCs.
36. Which leukemia is seen in 80% of adults with acute leukemia and exhibits proliferation of precursors of granulocytes?
a. Acute lymphocytic leukemia (ALL) c. Acute myelogenous leukemia (AML) b. Chronic lymphocytic leukemia (CLL) d. Chronic myelogenous leukemia (CML) 37. Which statements accurately describe chronic lymphocytic leukemia (select all that apply)?
a. Most common leukemia of adults d. Increased incidence in survivors of atomic bombs b. Only cure is bone marrow transplant e. Philadelphia chromosome is a diagnostic hallmark c. Neoplasm of activated B lymphocytes f. Mature-appearing but functionally inactive lymphocytes 38. What is the underlying cause of lymphadenopathy, splenomegaly, and hepatomegaly in leukemia?
a. The development of infection at these sites
b. Increased compensatory production of blood cells by these organs c. Infiltration of the organs by increased numbers of WBCs in the blood d. Normal hypertrophy of the organs in an attempt to destroy abnormal cells
39. A patient with acute myelogenous leukemia is considering a hematopoietic stem cell transplant and asks the nurse what is involved. What is the best response the nurse can give the patient?
a. “Your bone marrow is destroyed by radiation and new bone marrow cells from a matched donor are injected into your bones.”
b. “A specimen of your bone marrow may be aspirated and treated to destroy any leukemic cells and then reinfused when your disease becomes worse.”
c. “Leukemic cells and bone marrow stem cells are eliminated with chemotherapy and/or total-body radiation and new bone marrow cells from a donor are infused.”
d. “During chemotherapy and/or total-body irradiation to destroy all of your blood cells, you may be given transfusions of red blood cells and platelets to prevent complications.”
40. Indicate whether the following characteristics are associated with Hodgkin’s lymphoma (HL), non-Hodgkin’s lymphoma (NHL), or both (B).
a. Affects all ages
b. Presence of Reed-Sternberg cells c. Associated with Epstein-Barr virus d. Multiple histopathologic classifications e. Treated with radiation and chemotherapy f. Originates in lymph nodes in most patients g. Greater than 85% cure rate in stage I disease h. Often widely disseminated at time of diagnosis i. Ingested alcohol-induced pain at the site of disease
j. Primary initial clinical manifestation is painless lymph node enlargement
Chapter 31 Nursing Management: Hematologic Problems 125 41. What characteristics should the nurse be aware of in planning care for the patient with Hodgkin’s lymphoma?
a. Staging of Hodgkin’s lymphoma is not important to predict prognosis.
b. Nursing management of the patient undergoing treatment for Hodgkin’s lymphoma includes measures to prevent infection.
c. Hodgkin’s lymphoma is characterized by proliferation of malignant activated B cells that destroy the kidneys.
d. An important nursing intervention in the care of patients with Hodgkin’s lymphoma is increasing fluids to manage hypercalcemia.
42. Following a splenectomy for the treatment of ITP, the nurse would expect the patient’s laboratory test results to reveal which of the following?
a. Decreased RBCs c. Increased platelets
b. Decreased WBCs d. Increased immunoglobulins
43. Priority Decision: While receiving a unit of packed RBCs, the patient develops chills and a temperature of 102.2°F (39°C). What is the priority action for the nurse to take?
a. Stop the transfusion and instill normal saline.
b. Notify the health care provider and the blood bank.
c. Add a leukocyte reduction filter to the blood administration set.
d. Recognize this as a mild allergic transfusion reaction and slow the transfusion.
44. A patient with thrombocytopenia with active bleeding is to receive two units of platelets. To administer the platelets, what should the nurse do?
a. Check for ABO compatibility. c. Take vital signs every 15 minutes during the procedure.
b. Agitate the bag periodically during the transfusion. d. Refrigerate the second unit until the first unit has transfused.
45. Which type of transfusion reaction occurs with leukocyte or plasma protein incompatibility and may be avoided with leukocyte reduction filters?
a. Febrile reaction c. Acute hemolytic reaction
b. Allergic reaction d. Massive blood transfusion reaction
46. Which characteristics are related to an acute hemolytic transfusion reaction (select all that apply)?
a. ABO incompatibility d. Acute kidney injury occurs
b. Hypothermia common e. Hypocalcemia and hyperkalemia
c. Destruction of donor RBCs f. Epinephrine used for severe reaction
47. Delegation Decision: While administering an infusion of packed RBCs, which actions can the RN delegate to unlicensed assistive personnel (UAP) (select all that apply)?
a. Verify that the IV is patent.
b. Obtain the blood products from the blood bank.
c. Obtain vital signs before and after the first 15 minutes.
d. Monitor the blood transfusion rate and adjust as needed.
e. Assist the RN with checking patient identification and blood product identification data.
48. Priority Decision: The nurse is preparing to administer a blood transfusion. Number the actions in order of priority (1 is first priority action; 10 is last priority action).
a. Verify the order for the transfusion.
b. Ensure that the patient has a patent 18-gauge IV.
c. Prime the transfusion tubing and filter with normal saline.
d. Verify that the physician has discussed risks, benefits, and alternatives with the patient.
e. Obtain the blood product from the blood bank.
f. Ask another licensed person (nurse or MD) to assist in verifying the product identification and the patient identification.
g. Document outcomes in the patient record. Document vital signs, names of personnel, and starting and ending times.
h. Adjust the infusion rate and continue to monitor the patient every 30 minutes for up to an hour after the product is infused.
i. Infuse the first 50 mL over 15 minutes, staying with the patient.
j. Obtain the patient’s vital signs before starting the transfusion.
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CASE STUDY
Disseminated Intravascular Coagulation Patient Profile
N.T., a 35-year-old mother of two, is admitted in active labor to the labor and delivery department for delivery of her third child. She delivers a 9-lb boy following an unusually difficult and prolonged labor.
Objective Data
• During her recovery period, N.T. continues to have heavy uterine bleeding and a boggy fundus
• Her skin is pale and diaphoretic
• BP: 70/40
• HR: 150 bpm
• Although the placenta appeared intact on examination, she is suspected of having retained placental fragments, causing DIC
Discussion Questions
Using a separate sheet of paper, answer the following questions:
1. What is the pathologic mechanism that triggers DIC in N.T.?
2. What additional clinical findings would indicate the presence of DIC?
3. Describe the common laboratory findings that are indicative of DIC.
4. What therapeutic modalities are most appropriate for N.T. and why?
5. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?
Copyright © 2014 by Mosby, an imprint of Elsevier Inc. All rights reserved.
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