Lewis - Chapter 30: Hematologic Problems

In severely anemic patients, the nurse would expect to find:

A. dyspnea and tachycardia

B. cyanosis and pulmonary edema

C. cardiomegaly and pulmonary fibrosis

D. ventricular dysrhythmia and wheezing

A. dyspnea and tachycardia

When obtaining assessment data from a patient with a microcytic, hypochromic anemia, the nurse would question the patient about:

A. folic acid intake

B. dietary intake of iron

C. a history of gastric surgery

D. a history of sickle cell anemia

B

Nursing interventions for a patient with severe anemia related to peptic ulcer disease would include (select all that apply):

A. monitoring stools for guaiac

B. instruction for a high iron diet

C. taking vital signs every 8 hours

D. teaching self injection of erythropoietin

E. administration of cobalamin (vit B12) injections

A, B

The nursing management of a patient in sickle cell crisis includes (select all that apply):

A. monitoring CBC

B. blood transfusion if required and iron chelation

C. optimal pain management and oxygen therapy

D. rest as needed and DVT prophylaxis

E. administration of IV iron and diet high in iron content

A, B, C, D

A complication of the hyperviscosity of polycythemia is:

A. thrombosis

B. cardiomyopathy

C. pulmonary edema

D. disseminated intravascular coagulation (DIC)

A

DIC is a disorder in which:

A. the coagulation pathway is generally altered, leading to thrombus formation in all major blood vessels

B. an underlying disease depletes hemolytic factors in the blood, leading to diffuse thrombotic episodes and infarcts

C. a disease process stimulates coagulation process with resultant thrombosis, as well as depletion of clotting factors, leading to diffuse clotting and hemorrhage

D. an inherited predisposition causes a deficiency of clotting factors that leads to overstimulation of coagulation processes in the vasculature

C

When reviewing the patient's hematologic laboratory values after a splenectomy, the nurse would expect to find:

A. leukopenia

B. RBC abnormalities

C. decreased hemoglobin

D. increased platelet count

D

A 62-year old man with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. The nurse would expect the patient's laboratory findings to include

a. a hematocrit (Hct) of 38%.

b. an RBC count of 4,500,000/L.

c. normal red blood cell (RBC) indices.

d. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

ANS: D

The patient's clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.

Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first?

a. 44-year-old with sickle cell anemia who says "my eyes always look sort of yellow"

b. 23-year-old with no previous health problems who has a nontender lump in the axilla

c. 50-year-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue

d. 19-year-old with hemophilia who wants to learn to self-administer factor VII replacement

ANS: B

The patient's age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently.

When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care?

a. Discourage deep breathing to reduce risk for splenic rupture.

b. Teach the patient to use ibuprofen (Advil) for left upper quadrant pain.

c. Schedule immunization with the pneumococcal vaccine (Pneumovax).

d. Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery.

ANS: C

Asplenic patients are at high risk for infection with Pneumococcus and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth and the patient should be encouraged to take deep breaths

The nurse has obtained the health history, physical assessment data, and laboratory results shown in the accompanying figure for a patient admitted with aplastic anemia. Which information is most important to communicate to the health care provider?

a. Neutropenia

b. Increasing fatigue

c. Thrombocytopenia

d. Frequent constipation

ANS: A

The low white blood cell count indicates that the patient is at high risk for infection and needs immediate actions to diagnose and treat the cause of the leucopenia. The other information may require further assessment or treatment, but does not place the patient at immediate risk for complications.

A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?

ANS:

21

To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/minute or 21 drops/minute.

Which menu choice indicates that the patient understands the nurse's teaching about best dietary choices for iron-deficiency anemia?

a. Omelet and whole wheat toast

b. Cantaloupe and cottage cheese

c. Strawberry and banana fruit plate

d. Cornmeal muffin and orange juice

ANS: A

Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of

a. iron.

b. folic acid.

c. cobalamin (vitamin B12).

d. ascorbic acid (vitamin C).

ANS: B

Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.

A 52-year-old patient has a new diagnosis of pernicious anemia. The nurse determines that the patient understands the teaching about the disorder when the patient states, "I

a. need to start eating more red meat and liver."

b. will stop having a glass of wine with dinner."

c. could choose nasal spray rather than injections of vitamin B12."

d. will need to take a proton pump inhibitor like omeprazole (Prilosec)."

ANS: C

Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.

An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is to

a. provide a diet high in vitamin K.

b. alternate periods of rest and activity.

c. teach the patient how to avoid injury.

d. place the patient on protective isolation.

ANS: B

Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia.

Which patient statement to the nurse indicates a need for additional instruction about taking oral ferrous sulfate?

a. "I will call my health care provider if my stools turn black."

b. "I will take a stool softener if I feel constipated occasionally."

c. "I should take the iron with orange juice about an hour before eating."

d. "I should increase my fluid and fiber intake while I am taking iron tablets."

ANS: A

It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the doctor about this. The other patient statements are correct.

Which collaborative problem will the nurse include in a care plan for a patient admitted to the hospital with idiopathic aplastic anemia?

a. Potential complication: seizures

b. Potential complication: infection

c. Potential complication: neurogenic shock

d. Potential complication: pulmonary edema

ANS: B

Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema

It is important for the nurse providing care for a patient with sickle cell crisis to

a. limit the patient's intake of oral and IV fluids.

b. evaluate the effectiveness of opioid analgesics.

c. encourage the patient to ambulate as much as tolerated.

d. teach the patient about high-protein, high-calorie foods.

ANS: B

Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.

Which statement by a patient indicates good understanding of the nurse's teaching about prevention of sickle cell crisis?

a. "Home oxygen therapy is frequently used to decrease sickling."

b. "There are no effective medications that can help prevent sickling."

c. "Routine continuous dosage narcotics are prescribed to prevent a crisis."

d. "Risk for a crisis is decreased by having an annual influenza vaccination."

ANS: D

Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises.

Which instruction will the nurse plan to include in discharge teaching for the patient admitted with a sickle cell crisis?

a. Take a daily multivitamin with iron.

b. Limit fluids to 2 to 3 quarts per day.

c. Avoid exposure to crowds when possible.

d. Drink only two caffeinated beverages daily.

ANS: C

Exposure to crowds increases the patient's risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended.

The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse will plan to check the laboratory results for the

a. Schilling test.

b. bilirubin level.

c. stool occult blood test.

d. gastric analysis testing.

ANS: B

Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia.

The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from gastrointestinal hemorrhage. Which action can the nurse delegate to unlicensed assistive personnel (UAP)?

a. Verify the patient identification (ID) according to hospital policy.

b. Obtain the temperature, blood pressure, and pulse before the transfusion.

c. Double-check the product numbers on the PRBCs with the patient ID band.

d. Monitor the patient for shortness of breath or chest pain during the transfusion.

ANS: B

UAP education includes measurement of vital signs. UAP would report the vital signs to the registered nurse (RN). The other actions require more education and a larger scope of practice and should be done by licensed nursing staff members

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take?

a. Draw blood for a new crossmatch.

b. Send a urine specimen to the laboratory.

c. Administer PRN acetaminophen (Tylenol).

d. Give the PRN diphenhydramine (Benadryl).

ANS: C

The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine (Benadryl) is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.

A patient in the emergency department complains of back pain and difficulty breathing 15 minutes after a transfusion of packed red blood cells is started. The nurse's first action should be to

a. administer oxygen therapy at a high flow rate.

b. obtain a urine specimen to send to the laboratory.

c. notify the health care provider about the symptoms.

d. disconnect the transfusion and infuse normal saline.

ANS: D

The patient's symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.

Which patient should the nurse assign as the roommate for a patient who has aplastic anemia?

a. A patient with chronic heart failure

b. A patient who has viral pneumonia

c. A patient who has right leg cellulitis

d. A patient with multiple abdominal drains

ANS: A

Patients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of anemia, so the nurse should avoid assigning a roommate with any possible infectious process.

Which patient requires the most rapid assessment and care by the emergency department nurse?

a. The patient with hemochromatosis who reports abdominal pain

b. The patient with neutropenia who has a temperature of 101.8° F

c. The patient with sickle cell anemia who has had nausea and diarrhea for 24 hours

d. The patient with thrombocytopenia who has oozing after having a tooth extracted

ANS: B

A neutropenic patient with a fever is assumed to have an infection and is at risk for rapidly developing sepsis. Rapid assessment, cultures, and initiation of antibiotic therapy are needed. The other patients also require rapid assessment and care but not as urgently as the neutropenic patient.

A patient with septicemia develops prolonged bleeding from venipuncture sites and blood in the stools. Which action is most important for the nurse to take?

a. Avoid venipunctures.

b. Notify the patient's physician.

c. Apply sterile dressings to the sites.

d. Give prescribed proton-pump inhibitors.

ANS: B

The patient's new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin administration. The other actions also are appropriate, but the most important action should be to notify the physician so that DIC treatment can be initiated rapidly.

A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102° F (38.9° C), and severe back pain. Which physician order will the nurse implement first?

a. Administer morphine sulfate 4 mg IV.

b. Give acetaminophen (Tylenol) 650 mg.

c. Infuse normal saline 500 mL over 30 minutes.

d. Schedule complete blood count and coagulation studies.

ANS: C

The patient's blood pressure indicates hypovolemia caused by blood loss and should be addressed immediately to improve perfusion to vital organs. The other actions also are appropriate and should be rapidly implemented, but improving perfusion is the priority for this patient.