complex exam 2

An 82-year-old patient with a history of peripheral vascular disease is diagnosed with polycythemia vera. Given their age and comorbidities, which pharmacological intervention is prioritized alongside serial phlebotomy to mitigate the risk of thrombosis?

Hydroxyurea

A patient in the ICU has a baseline Hemoglobin (HGB) of 12 g/dL and a Hematocrit (HCT) of 36%. Over the course of 48 hours, diagnostic phlebotomy results in 200 mL of blood loss. Using the statistics provided in the source material, what is the expected HCT for this patient, assuming no other sources of blood loss?

32.2%

A patient with glucose-6-phosphate dehydrogenase (G6PD) deficiency is admitted for a severe UTI. Which of the following substances or medications must the nurse ensure are avoided to prevent a hemolytic crisis?

Nitrofurantoin

Chloramphenicol

Sulfonamides

Contrast the pathophysiology of Transfusion-Related Acute Lung Injury (TRALI) and Transfusion-Associated Circulatory Overload (TACO), identifying the clinical hallmark that differentiates them despite their similar presentations.

Both TRALI and TACO present as acute respiratory distress with dyspnea, hypoxia, and pulmonary edema. However, TACO is characterized by evidence of volume overload, whereas TRALI presents as noncardiogenic pulmonary edema without volume overload.

A patient in sickle cell vaso-occlusive crisis reports a pain level of 10/10 but appears calm and is watching television. What is the most appropriate nursing action based on the pathophysiology of chronic pain in Sickle Cell Disease (SCD)?

Administer the prescribed narcotic analgesia based on the patient’s self-report

The hallmark of Heparin-Induced Thrombocytopenia (HIT) is an unexplained thromboembolic event or a decrease in the platelet count to fewer than 150,000/mm3 or less than _____%of the patient's baseline.

50

A nurse is caring for a patient with severe neutropenia (Absolute Neutrophil Count <200/mm3). Which interventions are critical to include in the plan of care?

Administer antibacterial mouthwashes and perform meticulous oral care

Prohibit all digital rectal examinations and rectal temperature monitoring

Screen all diarrhea for Clostridium difficile

A patient with suspected Thrombotic Thrombocytopenic Purpura (TTP) presents with fever, confusion, and a platelet count of 15,000/mm3. Why is a platelet transfusion contraindicated in this scenario?

Transfused platelets may aggregate in the microvasculature, potentially causing organ infarction or death

Explain the self-perpetuating cycle of Disseminated Intravascular Coagulation (DIC) as it relates to the simultaneous occurrence of thrombosis and hemorrhage.

DIC begins with unregulated thrombin activity that causes diffuse intravascular clotting. This exhausts clotting factors and platelets faster than the body can replace them, while simultaneously activating the fibrinolytic system to dissolve clots. The resulting fibrin degradation products interfere with remaining clot formation, leading to systemic hemorrhage.

Anemia of chronic kidney injury typically manifests when the patient's creatinine clearance falls below _____ mL/min.

45

Which laboratory results would a nurse expect to see in the early acute phase of Disseminated Intravascular Coagulation (DIC)?

Decreased Fibrinogen level

Prolonged Prothrombin Time (PT)

Elevated D-dimer assay

A patient with Acute Myelogenous Leukemia (AML) is admitted with a leukocyte count of 120,000/mm3. They report a sudden onset of confusion and a severe headache. What emergent complication should the nurse anticipate?

Leukostasis

A 25-year-old female patient is being evaluated for potential Chronic Immune Thrombocytopenic Purpura (ITP). Which assessment findings or history items are consistent with this diagnosis?

Presence of petechiae and gingival bleeding

A history of systemic lupus erythematosus (SLE)

A nurse is administering Iron Dextran intravenously to a patient with severe anemia. Which action is the highest priority for patient safety?

Administer a test dose and observe the patient for at least one hour

An ICU patient requires frequent blood sampling for arterial blood gas (ABG) analysis. Propose three nursing strategies to reduce the impact of phlebotomy-induced anemia in this patient.

Strategies include eliminating standing orders for labs to question necessity, using noninvasive monitoring like pulse oximetry or capnography to reduce ABG frequency, and using devices that return waste blood to the patient during draws. Additionally, consolidating collections and using smaller pediatric collection tubes can minimize volume loss.

In patients with Polycythemia Vera, a mutation in the ____ gene causes the production of a protein that is constantly 'turned on,' leading to uncontrolled blood cell production.

JAK2

A patient with Hemophilia A is experiencing active joint bleeding (hemarthrosis). Which treatments or products are indicated for this patient?

Fresh Frozen Plasma (FFP)

Desmopressin acetate (DDAVP)

Factor VIII concentrate

Which specific finding on a peripheral blood smear would most strongly support a diagnosis of microangiopathic hemolytic anemia in a patient with suspected DIC or TTP?

Schistocytes

A nurse is preparing to administer a single unit of packed RBCs to a stable ICU patient with a hemoglobin of 7.2 g/dL. Which practices align with current evidence-based guidelines?

Request leukoreduced blood to decrease the risk of febrile reactions

Transfuse a single unit followed by clinical reassessment

Use a blood warmer if the patient has cold-reactive autoimmmune hemolytic anemia

How does Acute Myelogenous Leukemia (AML) lead to the development of anemia and thrombocytopenia in the absence of external bleeding?

AML involves the malignant proliferation of immature myeloid clones (blasts) in the bone marrow. These leukemic cells physically and metabolically encroach upon the bone marrow space, crowding out and suppressing the normal production of red blood cell and thrombocyte (platelet) precursors.

In megaloblastic anemia, vitamin B12​ replacement must usually be administered via injection because the nutrient is poorly absorbed from the gut.

Intramuscular

A patient with secondary polycythemia has an elevated hematocrit. The medical history includes obesity, heavy smoking, and chronic obstructive pulmonary disease (COPD). What is the primary physiological driver for this patient's increased RBC production?

Chronic hypoxia

Which findings in a patient's clinical presentation would complete the 'classic pentad' required for a definitive diagnosis of Thrombotic Thrombocytopenic Purpura (TTP)?

Neurologic abnormalities (e.g., confusion, seizures)

Microangiopathic hemolytic anemia

Renal dysfunction

A nurse is caring for an older adult patient. According to the 'Considerations for the Older Patient' box, which statement regarding anemia in this population is correct?

Oral iron supplements are poorly utilized in older adults

Which conditions are common causes of secondary thrombocytopenia due to increased sequestration of platelets in the spleen?

Liver disease

Tumor infiltration of the spleen

Portal hypertension

A patient with anemia of chronic disease should have a stool _____ test performed to systematically rule out occult gastrointestinal blood loss.

guaiac

A patient is undergoing treatment for severe aplastic anemia. Which of the following statements regarding their care is most accurate?

Bone marrow transplantation should be considered immediately if the patient is younger than 60

What is the primary difference in the pathophysiology of Polycythemia Vera compared to Secondary Polycythemia?

Polycythemia Vera is a myeloproliferative disorder caused by genetic mutations (often JAK2) resulting in increased RBC production. In contrast, Secondary Polycythemia is a normal physiological response to chronic hypoxia (such as high altitude or smoking) or inappropriate erythropoietin production from renal disease.

How does diagnostic phlebotomy impact hemoglobin and hematocrit levels in critically ill patients?

For every 100 mL of blood drawn for testing, there is an associated decrease in hemoglobin of 0.7 g/dL and hematocrit of 1.9%. Over several weeks in the ICU, even a conservative loss of 100 mL/day from diagnostic phlebotomy significantly contributes to anemia.

What are the specific clinical findings required for a diagnosis of Thrombotic Thrombocytopenic Purpura (TTP)?

A diagnosis of TTP is considered if a patient presents with thrombocytopenia and microangiopathic hemolytic anemia. Other classic findings include fever, fluctuating neurologic abnormalities (such as seizures or coma), and renal dysfunction.

Describe the hallmark indicators and immediate management of Heparin-Induced Thrombocytopenia (HIT).

The hallmark of HIT is a decrease in platelet count to less than 50% of baseline or fewer than 150,000/mm³, often occurring 4–14 days after starting heparin. Management requires immediate cessation of all heparin products and the initiation of a non-heparin anticoagulant like argatroban or bivalirudin.

Why are rectal examinations and rectal temperatures contraindicated in patients with neutropenia?

These procedures are avoided to prevent trauma to the fragile mucosa and the introduction of bacteria into the bloodstream. Because neutrophils are the first line of defense against organisms in the gastrointestinal tract, even minor injury can lead to overwhelming infection or sepsis.

What are the expected changes in hemoglobin (HGB) and hematocrit (HCT) following the administration of one unit of blood?

Following the transfusion of one unit of blood, the patient's hemoglobin is expected to increase by 1 point. Additionally, the hematocrit level is expected to rise by 3% per unit.

What are the primary nursing priorities for managing a patient experiencing a sickle cell vaso-occlusive crisis?

Management focuses on aggressive intravenous hydration to decrease blood viscosity and maintain renal perfusion, alongside steady doses of narcotics for intense pain. Nurses must also monitor for infection, provide oxygen if needed, and assess for complications like acute chest syndrome.

Describe the "self-perpetuating cycle" that occurs during Disseminated Intravascular Coagulation (DIC).

DIC involves the inappropriate, systemic triggering of the coagulation cascade, leading to diffuse intravascular fibrin formation and widespread clotting. This process depletes clotting factors and platelets faster than the body can replace them, resulting in simultaneous, unregulated hemorrhage.

What is the difference between Transfusion-Related Acute Lung Injury (TRALI) and Transfusion-Associated Circulatory Overload (TACO)?

Both TRALI and TACO present with dyspnea and pulmonary edema; however, TACO specifically includes evidence of volume overload. Patients with heart failure or renal impairment are at higher risk for TACO, which may be managed with diuretics like Lasix.

What role does the JAK2 gene mutation play in the development of Polycythemia Vera?

The JAK2 gene provides instructions for a protein that promotes cell growth and division. Mutations in this gene result in a protein that is constitutively activated (constantly turned on), which improves a cell's ability to survive and increases blood cell production.

Agranulocytosis

A severe neutrophil count of less than 200 cells/mm³.

Aplastic anemia

A condition of pancytopenia characterized by a deficiency of RBCs, WBCs, and platelets, often caused by unknown factors, drugs, or radiation.

D-dimer

A laboratory assay used to measure the breakdown products of fibrin; increased levels are a key indicator of DIC.

Erythropoiesis-Stimulating Agents (ESAs)

Medications such as epoetin that stimulate RBC production; their use in the ICU is generally not recommended due to the risk of deep vein thrombosis.

Hemostasis

A balanced network of procoagulants (clotting factors and platelets) and anticoagulants that prevents excessive bleeding.

JAK2 Gene

A gene that regulates cell proliferation; mutations are associated with Polycythemia Vera and constitutive activation of cell growth.

Leukopenia

An abnormally low number of white blood cells in the circulation.

Leukostasis

A condition where extremely high blast counts (over 100,000 cells/mm³) increase blood viscosity, leading to emboli and capillary aggregation.

Neutropenia

A neutrophil count of less than 1,500 cells/mm³, which increases susceptibility to bacterial and fungal infections.

Pancytopenia

A simultaneous decrease in all three types of blood cells: red blood cells, white blood cells, and platelets.

Phlebotomy

The removal of blood; serial phlebotomy is a first-line treatment for Polycythemia Vera to reduce hematocrit levels.

Polycythemia

An abnormality characterized by an increased concentration of hemoglobin due to reduced plasma volume or increased RBC mass.

Purpura Fulminans

A severe skin manifestation of DIC characterized by rapid-onset tissue necrosis and hemorrhage into the skin.

Reed-Sternberg Cells

Abnormal cells found in biopsied tissue that confirm a diagnosis of Hodgkin lymphoma.

Schistocytes

Fragmented red blood cells typically seen on a peripheral smear in patients with TTP or DIC.V

Vaso-occlusive crisis

A sudden, painful complication of Sickle Cell Disease where rigid, sickled cells obstruct small blood vessels and impede oxygen delivery.

A patient presents to the emergency department with a high-grade fever, sore throat, and a diffuse maculopapular rash. The patient reports unprotected sexual contact 3 weeks ago. A nucleic acid test (NAT) is positive for HIV-1 RNA, but the HIV-1/2 antibody immunoassay is non-reactive. Which stage of HIV infection is this patient currently experiencing?

Acute HIV infection

A nurse is caring for a patient with a CD4+ T-cell count of 85 cells/mm3. Which of the following opportunistic infections or conditions should the nurse prioritize for monitoring and prophylaxis based on this specific level of immunosuppression?

Cryptococcosis

Toxoplasmosis of the brain

Candidal esophagitis

In the HIV life cycle, the enzyme _____ is responsible for cleaving long HIV polyprotein chains into smaller, functional proteins, which allows the immature virus to become a mature, infectious particle.

protease

A patient with newly diagnosed acute myeloid leukemia (AML) and a white blood cell (WBC) count of 120,000/mm3 reports sudden shortness of breath and blurred vision. Which immediate intervention should the nurse anticipate?

Initiating urgent leukapheresis

Explain the pathophysiologic mechanism of Immune Reconstitution Inflammatory Syndrome (IRIS) and identify the primary lab changes associated with its onset.

IRIS occurs when a recovering immune system, following the initiation of ART, mounts an exaggerated inflammatory response against a previously diagnosed or subclinical pathogen. This is characterized by a rapid increase in CD4+ T-cell counts and a precipitous decline in HIV viral load.

A nurse is monitoring a patient 12 days after a hematopoietic stem cell transplant. The patient has developed a sudden high fever, a diffuse erythematous rash, and a 3 kg weight gain over 24 hours. The patient's absolute neutrophil count (ANC) is currently 150/mm3. Which condition does this constellation of symptoms most likely represent?

Engraftment syndrome

A patient is admitted with suspected Tumor Lysis Syndrome (TLS) following the first dose of chemotherapy for Burkitt lymphoma. Which laboratory findings should the nurse expect to see?

Serum uric acid of 12.5 mg/dL

Serum phosphorus of 7.0 mg/dL

Serum calcium of 7.1 mg/dL

Serum potassium of 6.2 mEq/L

A patient with metastatic lung cancer presents with facial swelling, a sensation of 'tightness' in their shirt collar (Stokes sign), and distended veins in the neck and upper chest. Which is the priority nursing assessment?

Assessing airway patency and respiratory effort

To calculate the corrected serum calcium for a patient with hypoalbuminemia, the nurse should subtract the patient's albumin from the normal albumin level, multiply by 0.8, and add this value to the reported serum calcium. This is necessary because approximately 40% to 50% of serum calcium is bound to the protein _______.

Albumin

A patient with breast cancer and known bone metastases is admitted with a serum calcium level of 14.2 mg/dL. Which initial medical treatment should the nurse prioritize?

Aggressive hydration with 0.9% NaCl at 250-300 L/h

Which of the following interventions are appropriate for a patient with Spinal Cord Compression (SCC) to prevent further neurologic injury?

Assisting with an urgent MRI of the spine

Administration of high-dose dexamethasone

Stabilizing the spine and maintaining bed rest

Compare the typical findings of Sinusoidal Obstruction Syndrome (SOS) with those of Septic Shock in a post-transplant patient. What clinical assessment find is most characteristic of SOS?

While both can cause hypotension and multi-organ failure, SOS is distinguished by painful hepatomegaly, jaundice (elevated bilirubin), and rapid weight gain due to fluid retention and ascites. The most characteristic finding of SOS is the reversal or stagnation of portal venous blood flow, often confirmed by Doppler ultrasound.

A health care worker experiences a deep needlestick injury with a needle used on a patient with a known high HIV viral load. What is the most appropriate action regarding postexposure prophylaxis (PEP)?

Initiate combination therapy with three of more antiretroviral drugs within hours of exposure

A patient with small cell lung cancer is diagnosed with Syndrome of Inappropriate Antidiuretic Hormone (SIADH). Which nursing interventions are appropriate for this metabolic emergency?

Monitoring for symptoms of hyponatremia such as confusion and seizures

Restricting total fluid intake to 500-1,000 mL/d

Administering IV conivaptan as ordered

A patient with HIV is being screened for cervical cancer using a Papanicolaou (Pap) test. This is considered an essential part of HIV care because the risk for ______ is significantly increased due to the prevalence of the Human Papillomavirus (HPV) in immunocompromised individuals.

Cervical intraepithelial neoplasia

Which assessment finding would most likely indicate a pericardial tamponade in a patient with esophageal cancer, as opposed to a simple pericardial effusion?

Pulsus paradoxus of 15 mmHg

A nurse is teaching a patient with CD4+ count of 180 cells/mm3 about vaccinations. According to the current guidelines, which vaccines should the patient receive or consider?

Human Papillomavirus (HPV)

Hepatitis B virus (HBV)

Streptococcus pneumoniae (Pneumococcal)

A patient with prolonged neutropenia following chemotherapy for leukemia develops sudden right lower quadrant abdominal pain, distention, and watery diarrhea. What is the most likely diagnosis?

Typhlitis (Neutropenic Enterocolitis)

A patient is receiving rasburicase for the treatment of hyperuricemia. The nurse is preparing to draw a follow-up uric acid level. How should the nurse handle the specimen to ensure an accurate result?

Collect the blood in a pre-chilled tube and transport it on ice immediately

A nurse is caring for a patient with head and neck cancer who is considered at high risk for carotid artery rupture. What are the 'cardinal signs' of an impending rupture, and what is the immediate nursing action if a rupture occurs?

Warning signs include a small 'trickle' of blood or oozing from the neck, unexplained oral bleeding, or a palpable pulse on top of the tumor. If rupture occurs, the nurse must immediately apply constant digital pressure to the carotid artery using a saline-soaked dressing and maintain the airway while calling for emergent surgical intervention.

A patient with HIV has a viral load of 450,000 copies/mL and a CD4+ count of 350 cells/mm3. They are beginning a regimen of two NRTIs and an Integrase Strand Transfer Inhibitor (INSTI). What is the primary goal of this therapy?

Achieve and maintain an undetectable viral load

Patients receiving certain chemotherapeutic agents like cyclophosphamide are at risk for SIADH, but they are also frequently prescribed aggressive hydration to prevent ______, a common bladder toxicity.

Hemorrhagic cystitis

Which of the following are recognized risk factors for the development of Sinusoidal Obstruction Syndrome (SOS) in cancer patients?

Pre-existing history of hepatitis

Total body irradiation (TBI)

Use of monoclonal antibodies like gemtuzumab

High-dose alkylating agents like busulfan

A nurse is caring for a patient with a malignant pleural effusion who has just undergone a large-volume thoracentesis. The patient suddenly develops a cough, dyspnea, and pink frothy sputum. What should the nurse suspect?

Reexpansion pulmonary edema

According to the CDC, all individuals between the ages of _____ and 65 should be screened for HIV at least once as part of routine health care, regardless of perceived risk.

15

A patient who underwent an orthotopic heart transplantation (OHT) is exercising as part of their rehabilitation. The nurse notices that the patient's heart rate increases much more slowly than a typical patient's during the warm-up phase. What is the physiological basis for this finding?

The donor heart is denervated, making it reliant on circulating catecholamines rather than direct sympathetic stimulation

Which of the following interventions are critical for the management of a potential organ donor during Phase 2 of hemodynamic management, after catecholamine stores are depleted?

Administration of dopamine or dobutamine at doses less than 10 mcg/kg/min if the heart is being considered for donation

Rapid replacement of blood volume using crystalloid or colloid intravenous fluids

Maintaining a mean arterial pressure (MAP) of 65 to 70 mmHg

In the context of hematopoietic stem cell transplantation (HSCT), is a process where chemotherapy or colony-stimulating factors are administered to the donor to drive progenitor cells from the bone marrow into the peripheral circulation for collection.

Mobilization

A patient awaiting a kidney transplant is found to have a high Panel Reactive Antibody (PRA) percentage. What does this clinical finding imply for the patient's transplantation prospects?

The patient has a high risk of rejection and will likely require a prospective crossmatch before any transplant

What are the three distinct stages of HIV infection, and how is the transition to the final stage defined?

The three stages are acute HIV infection, chronic HIV (clinical latency), and AIDS. Transition to AIDS is defined by a CD4+ T-cell count falling below 200 cells/mm³ or the development of specific opportunistic infections known as AIDS-defining conditions.

How does the HIV replication cycle progress from initial cell entry to the release of new infectious particles?

Replication begins with binding and fusion to a CD4+ receptor, followed by reverse transcription of RNA into DNA and integration into the host cell's nucleus. The virus then replicates through transcription and translation, eventually assembling into immature buds that mature into infectious particles via the protease enzyme.

Explain the "eclipse period" and "seroconversion" in the context of HIV diagnostic testing.

The eclipse period is the initial interval after contraction when no laboratory markers can consistently detect the virus in the plasma. Seroconversion marks the subsequent interval during which the body develops detectable antibodies, ending the period where an individual might test negative despite being infected.

What is the "HIV care continuum," and what is its primary goal regarding public health?

The HIV care continuum is a public health model that outlines the steps of diagnosing infection, linking individuals to medical care, and retaining them in treatment. Its ultimate objective is to help patients achieve and maintain viral suppression, which improves individual health and reduces transmission rates.

What are the clinical requirements and timeframes for initiating Postexposure Prophylaxis (PEP) after an occupational exposure?

PEP should be initiated as soon as possible, preferably within hours and no later than 72 hours after exposure, using a combination of three or more antiretroviral drugs. The regimen is prescribed for 28 days and requires strict adherence, with follow-up laboratory testing for toxicity and serology at intervals up to six months.

Define Immune Reconstitution Inflammatory Syndrome (IRIS) and identify when it typically occurs.

IRIS is a pathogen-specific inflammatory response triggered by the initiation or change of an ART regimen, causing a worsening of a previously diagnosed disease or the appearance of a new one. It usually presents 4 to 8 weeks after starting therapy and is characterized by a rapid decrease in viral load and an increase in CD4+ counts.

What is the pathophysiologic cause of Leukostasis, and which cancers are primarily associated with it?

Leukostasis is caused by an excess of circulating immature white blood cells (blasts) that create hyperviscosity, leading to microvascular occlusions and tissue ischemia. It is most commonly associated with acute leukemias and high-grade proliferative lymphomas, such as Burkitt lymphoma.

Describe the hallmark clinical signs of Superior Vena Cava Syndrome (SVCS).

Clinical signs include periorbital, facial, and neck swelling, often referred to as Stokes sign or tightness of the shirt collar. Other symptoms include distention of the veins in the thorax and upper extremities, dyspnea, cough, and visual disturbances or headaches caused by brain edema.

How does Tumor Lysis Syndrome (TLS) affect serum electrolyte levels, and what are the specific metabolic abnormalities involved?

TLS results in hyperkalemia, hyperphosphatemia, and hyperuricemia due to the rapid release of intracellular contents from dying cancer cells. These elevations cause the kidneys to excrete calcium, leading to secondary hypocalcemia and the potential for uric acid crystal deposition in the urinary tract.

What are the primary goals of medical management for a patient experiencing Spinal Cord Compression (SCC)?

The primary goals are to preserve motor function, reduce further neurologic damage, and effectively control pain. Management typically involves high-dose corticosteroids to reduce inflammation, followed by radiation, surgery (such as laminectomy), or chemotherapy depending on the tumor type.

Absolute Neutrophil Count (ANC)

The actual number of granulocytes available for phagocytic activity; used to classify the severity of leukopenia.

Antiretroviral Therapy (ART)

The actual number of granulocytes available for phagocytic activity; used to classify the severity of leukopenia.

Bisphosphonates

A class of drugs (e.g., zoledronic acid) used to prevent bone demineralization and treat malignancy-associated hypercalcemia.

Cardiac Tamponade

An emergency where excess pericardial fluid or tumor compression prevents the heart from filling and contracting properly.

Carotid Artery Rupture

A life-threatening hemorrhage ("blowout") caused by tumor erosion, radiation damage, or surgical manipulation of the carotid vessel.

CD4+ T-cell

A type of lymphocyte targeted by HIV; its count is the primary indicator of immune function and the standard for staging HIV/AIDS.

Eclipse Period

The initial phase of HIV infection (approx. 10 days) where no laboratory markers are consistently detectable in the blood.

Engraftment Syndrome

A disorder occurring during the return of bone marrow growth after transplant, characterized by fever, rash, and capillary leak.