Hematology and Oncology Review Notes

Complete Blood Count Review

• Scenario: Patient admitted for knee arthroscopy.
• Question: Which value is most important to report before surgery?
  • Hematocrit: 33%
  • Hemoglobin: 10.9 g/dL
  • Platelets: 426,000/mm³
  • White blood cell count: 16,000/mm³
• Answer: White blood cell count (WBC) is elevated, indicating a potential infection.
• Rationale: Surgery should not be performed if the patient has an active infection to avoid complications.

Packed Red Blood Cells (PRBCs) Administration

• Scenario: Orientation for a new RN administering PRBCs to a patient with blood loss during surgery.
• Question: Which action by the new RN requires immediate intervention?
  • Waiting 20 minutes after obtaining PRBCs before starting infusion.
  • Starting an IV line with a 22-gauge catheter.
  • Priming the transfusion set with D_5 and lactated ringers.
  • Telling the patient PRBCs may cause a serious transfusion reaction.
• Answer: Priming the transfusion set with D_5 and lactated ringers.
• Rationale: PRBCs should only be primed with normal saline to prevent reactions and cell damage.

Sickle Cell Crisis

• Scenario: 32-year-old patient with sickle cell anemia admitted during a sickle cell crisis.
• Question: Which action should be implemented first?
  • Morphine sulfate 4-8 mg IV every hour as needed.
  • Administer 100% oxygen via non-rebreather mask.
  • Start a 14-gauge IV and infuse normal saline at 200 mL/hour.
  • Administer Pneumovax and influenza vaccine.
• Answer: Administer 100% oxygen via non-rebreather mask.
• Rationale: Prioritize oxygenation to prevent further sickling of cells. Pain management and hydration are also important but secondary to oxygenation. Hypoxia (e.g., from skiing at high altitude) can trigger a crisis.
  • Treatment Strategy: Hyperoxygenate, manage pain, and hydrate.

Delegating Tasks for Anemia

• Scenario: 78-year-old patient admitted with anemia due to possible GI bleed.
• Question: Which activity can be delegated to an experienced UAP?
  • Obtain stool specimen for fecal blood test.
  • Have the patient sign a colonoscopy consent form.
  • Administer prescribed GoLYTELY.
  • Check for allergies to contrast dye before a GI test.
• Answer: Obtain stool specimen for fecal blood test.
• Rationale: Stool specimen collection is within the scope of practice for an experienced UAP. Other tasks require RN-level assessment, teaching, or intervention.

Patient Assignment: Float Nurse

• Scenario: Charge nurse assigning patients to a float nurse from the PACU.
• Question: Which patient is best assigned to the float nurse?
  • 30-year-old with thalassemia major requiring subcutaneous desferral infusion.
  • 43-year-old with multiple myeloma.
  • 52-year-old with chronic GI bleed returning from colonoscopy.
  • 65-year-old with pernicious anemia admitted for B12 injections.
• Answer: 52-year-old patient with chronic GI bleed returning from colonoscopy.
• Rationale: The float nurse from PACU is familiar with post-procedure monitoring, making this assignment appropriate. The patient has a chronic condition.

Pancytopenia Room Assignment

• Scenario: Making a room assignment for a newly arrived patient with pancytopenia.
• Question: Which patient would be the best roommate?
  • Patient with digoxin toxicity.
  • Patient with viral pneumonia.
  • Patient with shingles.
  • Patient with cellulitis.
• Answer: Patient with digoxin toxicity.
• Rationale: Pancytopenia indicates a compromised immune system, so the roommate should not have a contagious condition.

Chemotherapy and Thrombocytopenia

• Scenario: 67-year-old receiving chemotherapy for lung cancer admitted with thrombocytopenia.
• Question: Which statement made by the patient during admission is most concerning?
  • "I noticed that I bruise more easily since chemo started."
  • "My bowel movements are soft and dark brown."
  • "I take aspirin every morning for my history of angina."
  • "My appetite has decreased since chemotherapy."
• Answer: "I take aspirin every morning for my history of angina."
• Rationale: Thrombocytopenia increases bleeding risk, and aspirin further inhibits platelet function.

Hemophilia A

• Scenario: Patient with hemophilia A admitted to the ED after a car accident.
• Question: Which action should be implemented first?
  • Transport to radiology for cervical spine X-ray.
  • Transfuse factor VII concentrate.
  • Type and crossmatch for 4 units of PRBCs.
  • Infuse normal saline at 250 mL/hour.
• Answer: Transfuse factor VII concentrate.
• Rationale: Hemophilia A involves a deficiency in clotting factor VIII; the immediate priority is to replace this factor to prevent/control bleeding.

Coumadin (Warfarin) Teaching

• Scenario: Home health nurse obtaining admission history for a patient with DVT taking Coumadin 2 mg daily.
• Question: Which statement indicates a need for additional teaching?
  • "I've started to eat more healthy foods like green salad and fruit."
  • "The doctor said that it is important to avoid becoming constipated."
  • "Coumadin makes me feel a little nauseated unless I take it with food."
  • "I will need to have some blood testing done once or twice a week."
• Answer: "I've started to eat more healthy foods like green salad and fruit."
• Rationale: Consuming large amounts of Vitamin K can affect INR levels, requiring medication adjustments.

Disseminated Intravascular Coagulation (DIC)

• Scenario: Patient in the ICU with DIC associated with gram-negative infection.
• Question: Which assessment has the most immediate implications?
  • No palpable radial or pedal pulses.
  • Patient reports chest pain.
  • Oxygen saturation is 87%.
  • Mottling of hands and feet.
• Answer: Patient reports chest pain.
• Rationale: Chest pain suggests possible thrombosis or embolism, which needs immediate evaluation in the context of DIC.

Hodgkin's Disease and Anxiety

• Scenario: 22-year-old with stage one Hodgkin's disease admitted for radiation therapy expresses fear of dying.
• Question: Most appropriate response?
  • "Many individuals with this diagnosis…"
  • "Perhaps you should ask the doctor…"
  • "Tell me a little more about your fear of dying."
  • "Most people with stage one Hodgkin’s disease survive."
• Answer: "Tell me a little more about your fear of dying."
• Rationale: Encourage the patient to express their feelings.

Prioritization of Assessment

• Scenario: Receiving change-of-shift report. Which patient to assess first?
  • 26yo with thalassemia, hemoglobin of 8, order for PRBCs.
  • 44yo admitted 3 days ago for sickle cell crisis, ordered CT treatment.
  • 50yo with stage 4 non-Hodgkin's lymphoma, crying and stating they are afraid of dying.
  • 69yo with chemo-induced neutropenia, oral temperature of 100.1°F.
• Answer: 69yo with chemo-induced neutropenia, oral temperature of 100.1°F.
• Rationale: This patient is at highest risk for rapid deterioration due to infection. Neutropenia impairs the immune system’s ability to fight infection, so a fever is always concerning.

Chronic Lymphocytic Leukemia

• Scenario: Patient in a long term care facility who has chronic lymphocytic leukemia has a nursing diagnosis of activity intolerance related to weakness in anemia.
• Question: Which nursing activity will you delegate to the UAP?
  • Evaluating the patient's response to normal activities.
  • Checking the patient's blood pressure and pulse rate after ambulation.
  • Determining which self-care activities the patient can do independently.
  • Assisting the patient in choosing a diet that won't.
• Answer: Checking the patient's blood pressure and pulse rate after ambulation.

Transfusion Reaction

• Scenario: A transfusion of PRBCs has been infusing for five minutes when the patient becomes flushed, tachypneic, and says, "I'm having chills. Please give me a blanket."
• Question: Which action should you take first?
  • Get him a blanket.
  • Check the patient's temperature.
  • Stop the transfusion.
  • Give oxygen.
• Answer: Stop the transfusion.

LPN Scope of Practice

• Scenario: A group of patients is assigned to an RN/LPN team. Which patient should the LPN be assigned to provide patient care and administer medications?
  • A 36-year-old with chronic kidney failure who will need subcu injection of..
  • A 39-year-old with hemophilia B who's been admitted to routine transfusion of.
  • A 50-year-old diagnosed with polycythemia vera who will require phlebotomy.
  • A 55-year-old with a history of stem cell transplantation Okay. That's fine. Yeah.
• Answer: A 36-year-old with chronic kidney failure who will need subcu injection of..
• Rationale: LPNs can administer subcutaneous injections to stable patients.

Multiple Myeloma

• Scenario: You obtain the following data about a patient with multiple myeloma. Which information has the most immediate implications for patients here?
  • The patient reports chronic bone pain.
  • The blood uric acid level is very elevated.
  • The twenty twenty four hour urine test shows Vince Jones protein.
  • The patient reports new onset late night.
• Answer: The patient reports new onset late night.

Splenectomy

• Scenario: The nurse in the outpatient clinic is assessing a 22-year-old who requires his splenectomy after a recent motor motor vehicle accident.
• Question: Which information obtained during the assessment of will be of the most immediate concern to the nurse?
  • The patient engages in unprotected sex.
  • Oral temperature of a 100.
  • There's abdominal pain with with palpation.
  • The patient admits to occasional marijuana.
• Answer: Oral temperature of a 100.

Graft-Versus-Host Disease

• Scenario: A patient with graft versus host disease after a bone marrow transplant is being cared for on your on the medical unit. Which nursing activity is best delegated to a travel RN?
  • Administering oral Sandimmune to the patient, the autoimmune suppressive medication.
  • Giving the assessing the patient for signs of infection caused by graft versus host disease
  • Infusing D_5 and abnormal saline, a hundred and twenty five milliliters an hour to the patient.
  • Educating the patient about ways to prevent and detect infection.
• Answer: Infusing D_5 and abnormal saline, a hundred and twenty five milliliters an hour to the patient.

Absolute Neutrophil Count

• Scenario: You're the charge nurse on the oncology unit. When a patient with an absolute neutrophil count is low, I'm not gonna say it is admitted. Which staff member should you assign to provide care for this patient under the supervision of an inexperienced oncology RN?
  • An LPN who's floated from the same day surgery unit.
  • RN from a staffing agency who's being oriented to the oncology unit.
  • An LPN with two years of experience on the oncology unit, or
  • An RN who recently transferred to the oncology unit from the ED.
• Answer: An LPN with two years of experience on the oncology unit

Chronic Myeloid Leukemia

• Scenario: You're transferring a patient with newly diagnosed chronic myeloid leukemia to a long term care facility. Which information is most important to communicate to the long term care charge nurse before transferring the patient?
  • Philadelphia chromosome is present in the patient's blood smear.
  • Glucose level is elevated as a result of prednisone therapy.
  • There's been a 20 pound weight loss over the last year.
  • The patient's chemotherapy has resulted in neutropenia.
• Answer: The patient's chemotherapy has resulted in neutropenia.

Acute Myelogenous Leukemia

• Scenario: You have a patient with acute myelogenous leukemia who's receiving chemotherapy. What assessment finding requires the most rapid action?
  • Potassium, 7.8.
  • Urine output less than intake by 400 mils.
  • Inflammation and redness of oral mucosa.
  • Echymosis present on the anterior trunk.
• Answer: Potassium, 7.8.

Sanimmune Following Organ Transplantation

• Scenario: Your patient has been receiving Sanimmune San immune following an organ transplantation and is experiencing the following symptoms. Symptoms. Which one is the most concerned?
  • Bleeding of the gums while brushing the teeth,
  • Nontender lump in the right groin,
  • Occasional nausea after taking his medication,
  • Numbness and tingling in the feet.
• Answer: Nontender lump in the right groin

Hodgkin's Lymphoma

• Scenario: So your patient with Hodgkin's lymphoma is re he's receiving radiation therapy to the groin area, has skin redness and tenderness in the area being irradiated. Which nursing activity should you delegate to the UAP?
  • Checking the skin for signs of redness and peeling.
  • Assisting the patient in choosing appropriate clothing,
  • Explaining good skin care to the patient's family,
  • Cleaning the skin over the area daily with mild soap.
• Answer: Assisting the patient in choosing appropriate clothing

Acute Myelogenous Leukemia Arriving to the Medical Clinic

• Scenario: After you receive the change of ship report, which patient will you assess first?
  • 20 year old with possible acute myelogenous I can't say it, leukemia who has just arrived to the medical clinic. That's number one.
  • 38 year old with aplastic anemia who needs teaching about decreasing infection risk before discharge.
  • Number three, a 40 year old with lymphedema who requires help in putting on compression stocking stockings before getting out of bed.
  • Or number four, a 60 year old with non Hodgkin's lymphoma who is refusing the prescribed chemotherapy regimen regimen.
• Answer: 20 year old with possible acute myelogenous I can't say it, leukemia who has just arrived to the medical clinic