A patient with severe anemia is admitted to the hospital. Due to
religious beliefs, the patient is refusing blood transfusions. The
nurse anticipates drug therapy with which drug to stimulate the
production of red blood cells?
a) Eltrobopag (Promacta)
b)
Epoetin alfa (Epogen)
c) Filgrastim (Neupogen)
d)
Sargramostim (Leukine)
Ans: b
Erythropoietin (epoetin alfa [Epogen, Procrit]) is an effective alternative treatment for patients with chronic anemia secondary to diminished levels of erythropoietin. This medication stimulates erythropoiesis.
A nurse is completing a detailed health history and assessment in the
electronic medical record (EMR) on a pt with a disorder of
hematopoietic system.. Based on the pt's responses, which of the
following symptoms is most common complaint associated with
hematologic diseases?
a) Dyspnea
b) Severe headaches
c)
Extreme Fatigue
d) Blurred vision
ans: c
During a blood transfusion with packed red blood cells (RBCs), a
patient begins to complain of chills, low back pain, and nausea. What
priority action should the nurse take?
a) D/c the infusion STAT
and maintain the IV line with normal saline solution using new IV
tubing
b) D/c the infusion STAT and notify the
physician
c)slow the infusion rate and continue to monitor the pt
q15min
d) Observe for additional symptoms and notify the physician
ans: A
The following steps are taken to determine the type and
severity of the reaction: Stop the transfusion. Maintain the IV line
with normal sailine solution through new IV tubing, administered at a
slow rate. Assess the pt carefully. Notify Dr. Continue to monitor the
pt's vital signs and resp, cardio, and renal status. Notify the blood
bank that a suspected transfusion reaction has occurred and send the
blood container and tubing to the blood bank for repeat typing and culture.
Which of the following is a symptom of severe
thrombocytopenia?
a) Petechiae
b) inflammation of the
tongue
c) Dyspnea
d) Inflammation of the mouth
ans: A
pts with severe thrombocytopenia have petechiae (pinpoint
hemorrhagic lesions, usually more prominent on the trunk or anterior
aspects of the lower extremities)
A pt comes to the ER c/o enlarged tongue. The tongue appears smooth
and beefy red in color. The nurse also observes a 5cm incision on the
ULQ of the abd. When questions, the pt states "I had a partioal
gastrostomy 2 years ago" Based on this information, the nurse
attributes these symptons to which of the following problems?
a)
Folic acid deficiency
b) Vitamin A deficiency
c) Vitamin C
deficiency
d) Vitamin B12 deficiency
Ans: D
Vitamin B12 is found only in foods of animal origin,
strict vegetarians may ingest little B12. B12 combines with intrinsic
factor produced in the stomach. The B12 intrinsic factor complex is
absorbed in the distal ileum. People who have had a partial or full
gastrectomy may have limited amounts of intrinsic factor, and
therefore the absorption of B12 may be diminished. The effects may not
be noticed for 204 years. This results in megaloblastic anemia.
Which of the following nursing interventions should be incorporated
into the plan of care for a patient with impaired liver function and
low albumin levels?
a) Implement neutropenic precautions
b)
Apply prolonged pressure to needle sites or other sources of external
bleeding
c) Monitor of edema at least once per shift
d)
Monitor temperature at least once per shift
ans: C
Albumin is particularly important for the maintenance of
fluid balance within the vascular system. Capillary walls are
impermeable to albumin, so its presence in the plasma created an
osmotic force that keeps fluid within the vascular space. People with
impaired hepatic function may have low concentrations of albumin, with
a resultant decrease in osmotic pressure and the development of edema.
A patient with Hodgkin's disease had a bone marrow biopsy yesterday
and is complaining of aching, rated at a 5 out of 10, at the biopsy
site. After assessing the biopsy site, which of the following nursing
interventions is most appropriate?
a) Notify the
physician
b) Administer the ordered acetaminophen (tylenol) 500mg
po
c) Administer the ordered aspirin (ASA) 325mg po
d)
Reposistion the patient to a high fowler's postion and continue to
monitor the pain
ans: b
After the marrow sample in obtained, pressure is applied
to the site for several minutes. The site is then covered with a
sterile dressing. Most patients have no discomfort after, but the site
may ache for 1 or 2 days. Warm tub baths and a mild analgesic agent
may be useful. Aspirin containing analgesic agents should be avoided
because of potential bleeding.
A nurse is reviewing a patient's morning labs and notes a left shift
in the band cells. Based on this observation, what interpretation can
the nurse make from these results?
a) The patient may be
developing anemia
b) The patient may be developing an
infection
c) The patient has thrombocytopenia
d) The patient
has leukopenia
ans: b
An increased number of band cells is sometimes called a
left shift or shift to the left. Anemia refers to decreased red cell
mass. Leukopenia refers to a less-than-normal amount of WBC.
Thrombocytopenia refers to a lower than normal platelet count.
Which of the following terms refers to a form of WBC involved in
immune response?
a) Spherocyte
b) Lymphocyte
c)
Granulocyte
d) Thrombocyte
ans: b
Mature lymphocytes are the principal cells of the immune
system, producing antibodies and identifying other cells and organisms
as "foreign".
The nurse is completing a pretransfusion assessment to determine the
hx of previous transfusions as well as previous reactions for a female
pt. What is the most important information to obtain prior to the
transfusion?
a) # of pregnancies
b) Family hx of transfusion
reactions
c) pts dx
d) Pts age
ans: a
The nurse assesses the # of pregnancies a woman has had
bc a high number can increase her risk of reaction due to antibodies
developed from exposure to fetal circulation.
A pt who has idiopathic thrombocytopenia purpura (ITP) has a
critially low platelet count. Which nursing intervention will be
included in the care plan for a patient with ITP?
a) Enforce
strict contact isolation
b) administer eltronbopag
(promacta)
c) Place patient in a private room
d) Administer
epoetin alfa (Epogen)
ans: b
Thrombopoietin (TPO) is a cytokine that is necessary for
the proliferation of megakaryocytes and subsequent platelet formation.
Nonimmunogenic second-generation thrombopoietic growth factors
(romiplastin [Nplate] and eltrombopag [Promacta]) were recently
approved for the treatment of idiopathic thrombocytopenia purpura
1. A patient with a hematologic disorder asks the nurse how the body
forms blood cells. The nurse should describe a process that takes
place where?
A) In the spleen
B) In the kidneys
C) In
the bone marrow
D) In the liver
Ans: C
Feedback:
Bone marrow is the primary site for
hematopoiesis. The liver and spleen may be involved during embryonic
development or when marrow is destroyed. The kidneys release
erythropoietin, which stimulates the marrow to increase production of
red blood cells (RBCs). However, blood cells are not primarily formed
in the spleen, kidneys, or liver.
2. A man suffers a leg wound which causes minor blood loss. As a
result of bleeding, the process of primary hemostasis is activated.
What occurs in primary hemostasis?
A) Severed blood vessels
constrict.
B) Thromboplastin is released.
C) Prothrombin is
converted to thrombin.
D) Fibrin is lysed.
Ans: A
Feedback:
Primary hemostasis involves the severed
vessel constricting and platelets collecting at the injury site.
Secondary hemostasis occurs when thromboplastin is released,
prothrombin converts to thrombin, and fibrin is lysed.
3. A patient has come to the OB/GYN clinic due to recent heavy
menstrual flow. Because of the patient’s consequent increase in RBC
production, the nurse knows that the patient may need to increase her
daily intake of what substance?
A) Vitamin E
B) Vitamin
D
C) Iron
D) Magnesium
Ans: C
Feedback:
To replace blood loss, the rate of red
cell production increases. Iron is incorporated into hemoglobin.
Vitamins E and D and magnesium do not need to be increased when RBC
production is increased.
4. The nurse is planning the care of a patient with a nutritional
deficit and a diagnosis of megaloblastic anemia. The nurse should
recognize that this patient’s health problem is due to what?
A)
Production of inadequate quantities of RBCs
B) Premature release
of immature RBCs
C) Injury to the RBCs in circulation
D)
Abnormalities in the structure and function RBCs
Ans: D
Feedback:
Vitamin B12 and folic acid deficiencies
are characterized by the production of abnormally large erythrocytes
called megaloblasts. Because these cells are abnormal, many are
sequestered (trapped) while still in the bone marrow, and their rate
of release is decreased. Some of these cells actually die in the
marrow before they can be released into the circulation. This results
in megaloblastic anemia. This pathologic process does not involve
inadequate production, premature release, or injury to existing RBCs.
5. A nurse is caring for a patient who undergoing preliminary testing
for a hematologic disorder. What sign or symptom most likely suggests
a potential hematologic disorder?
A) Sudden change in level of
consciousness (LOC)
B) Recurrent infections
C)
Anaphylaxis
D) Severe fatigue
Ans: D
Feedback:
The most common indicator of hematologic
disease is extreme fatigue. This is more common than changes in LOC,
infections, or analphylaxis.
6. The nurse caring for a patient receiving a transfusion notes that
15 minutes after the infusion of packed red blood cells (PRBCs) has
begun, the patient is having difficulty breathing and complains of
severe chest tightness. What is the most appropriate initial action
for the nurse to take?
A) Notify the patient’s physician.
B)
Stop the transfusion immediately.
C) Remove the patient’s IV
access.
D) Assess the patient’s chest sounds and vital signs.
Ans: B
Feedback:
Vascular collapse, bronchospasm,
laryngeal edema, shock, fever, chills, and jugular vein distension are
severe reactions. The nurse should discontinue the transfusion
immediately, monitor the patient’s vital signs, and notify the
physician. The blood container and tubing should be sent to the blood
bank. A blood and urine specimen may be needed if a transfusion
reaction or a bacterial infection is suspected. The patient’s IV
access should not be removed.
7. The nurse is describing the role of plasminogen in the clotting
cascade. Where in the body is plasminogen present?
A) Myocardial
muscle tissue
B) All body fluids
C) Cerebral tissue
D)
Venous and arterial vessel walls
Ans: B
Feedback:
Plasminogen, which is present in all
body fluids, circulates with fibrinogen. Plasminogen is found in body
fluids, not tissue.
8. The nurse is caring for a patient who has developed scar tissue in
many of the areas that normally produce blood cells. What organs can
become active in blood cell production by the process of
extramedullary hematopoiesis?
A) Spleen and kidneys
B)
Kidneys and pancreas
C) Pancreas and liver
D) Liver and spleen
Ans: D
Feedback:
In adults with disease that causes
marrow destruction, fibrosis, or scarring, the liver and spleen can
also resume production of blood cells by a process known as
extramedullary hematopoiesis. The kidneys and pancreas do not produce
blood cells for the body.
9. Through the process of hematopoiesis, stem cells differentiate
into either myeloid or lymphoid stem cells. Into what do myeloid stem
cells further differentiate? Select all that apply.
A)
Leukocytes
B) Natural killer cells
C) Cytokines
D)
Platelets
E) Erythrocytes
Ans: A, D, E
Feedback:
Myeloid stem cells differentiate
into three broad cell types: erythrocytes, leukocytes, and platelets.
Natural killer cells and cytokines do not originate as myeloid stem cells.
10. A patient’s wound has begun to heal and the blood clot which
formed is no longer necessary. When a blood clot is no longer needed,
the fibrinogen and fibrin will be digested by which of the
following?
A) Plasminogen
B) Thrombin
C)
Prothrombin
D) Plasmin
Ans: D
Feedback:
The substance plasminogen is required to
lyse (break down) the fibrin. Plasminogen, which is present in all
body fluids, circulates with fibrinogen and is therefore incorporated
into the fibrin clot as it forms. When the clot is no longer needed
(e.g., after an injured blood vessel has healed), the plasminogen is
activated to form plasmin. Plasmin digests the fibrinogen and fibrin.
Prothrombin is converted to thrombin, which in turn catalyzes the
conversion of fibrinogen to fibrin so a clot can form.
11. A patient undergoing a hip replacement has autologous blood on
standby if a transfusion is needed. What is the primary advantage of
autologous transfusions?
A) Safe transfusion for patients with a
history of transfusion reactions
B) Prevention of viral
infections from another person’s blood
C) Avoidance of
complications in patients with alloantibodies
D) Prevention of alloimmunization
Ans: B
Feedback:
The primary advantage of autologous
transfusions is the prevention of viral infections from another
person’s blood. Other secondary advantages include safe transfusion
for patients with a history of transfusion reactions, prevention of
alloimmunization, and avoidance of complications in patients with alloantibodies.
12. A patient has been diagnosed with a lymphoid stem cell defect.
This patient has the potential for a problem involving which of the
following?
A) Plasma cells
B) Neutrophils
C) Red blood
cells
D) Platelets
Ans: A
Feedback:
A defect in a myeloid stem cell can
cause problems with erythrocyte, leukocyte, and platelet production.
In contrast, a defect in the lymphoid stem cell can cause problems
with T or B lymphocytes, plasma cells (a more differentiated form of B
lymphocyte), or natural killer (NK) cells.
13. The nurse is describing normal RBC physiology to a patient who
has a diagnosis of anemia. The nurse should explain that the RBCs
consist primarily of which of the following?
A)
Plasminogen
B) Hemoglobin
C) Hematocrit
D) Fibrin
Ans: B
Feedback:
Mature erythrocytes consist primarily of
hemoglobin, which contains iron and makes up 95% of the cell mass.
RBCs are not made of fibrin or plasminogen. Hematocrit is a measure of
RBC volume in whole blood.
14. The nurse educating a patient with anemia is describing the
process of RBC production. When the patient’s kidneys sense a low
level of oxygen in circulating blood, what physiologic response is
initiated?
A) Increased stem cell synthesis
B) Decreased
respiratory rate
C) Arterial vasoconstriction
D) Increased
production of erythropoietin
Ans: D
Feedback:
If the kidney detects low levels of
oxygen, as occurs when fewer red cells are available to bind oxygen
(i.e., anemia), erythropoietin levels increase. The body does not
compensate with vasoconstriction, decreased respiration, or increased
stem cell activity.
15. An older adult client is exhibiting many of the characteristic
signs and symptoms of iron deficiency. In addition to a complete blood
count, what diagnostic assessment should the nurse anticipate?
A)
Stool for occult blood
B) Bone marrow biopsy
C) Lumbar
puncture
D) Urinalysis
Ans: A
Feedback:
Iron deficiency in the adult generally
indicates blood loss (e.g., from bleeding in the GI tract or heavy
menstrual flow). Bleeding in the GI tract can be preliminarily
identified by testing stool for the presence of blood. A bone marrow
biopsy would not be undertaken for the sole purpose of investigating
an iron deficiency. Lumbar puncture and urinalysis would not be
clinically relevant.
16. A patient is being treated for the effects of a longstanding
vitamin B12 deficiency. What aspect of the patient’s health history
would most likely predispose her to this deficiency?
A) The
patient has irregular menstrual periods.
B) The patient is a
vegan.
C) The patient donated blood 60 days ago.
D) The
patient frequently smokes marijuana.
Ans: B
Feedback:
Because vitamin B12 is found only in
foods of animal origin, strict vegetarians may ingest little vitamin
B12. Irregular menstrual periods, marijuana use, and blood donation
would not precipitate a vitamin B12 deficiency.
17. The nurse’s review of a patient’s most recent blood work reveals
a significant increase in the number of band cells. The nurse’s
subsequent assessment should focus on which of the following?
A)
Respiratory function
B) Evidence of decreased tissue
perfusion
C) Signs and symptoms of infection
D) Recent
changes in activity tolerance
Ans: C
Feedback:
Ordinarily, band cells account for only
a small percentage of circulating granulocytes, although their
percentage can increase greatly under conditions in which neutrophil
production increases, such as infection. This finding is not
suggestive of problems with oxygenation and subsequent activity intolerance.
18. A nurse is educating a patient about the role of B lymphocytes.
The nurse’s description will include which of the following
physiologic processes?
A) Stem cell differentiation
B)
Cytokine production
C) Phagocytosis
D) Antibody production
Ans: D
Feedback:
B lymphocytes are capable of
differentiating into plasma cells. Plasma cells, in turn, produce
antibodies. Cytokines are produced by NK cells. Stem cell
differentiation greatly precedes B lymphocyte production.
19. A patient’s most recent blood work reveals low levels of albumin.
This assessment finding should suggest the possibility of what nursing
diagnosis?
A) Risk for imbalanced fluid volume related to low
albumin
B) Risk for infection related to low albumin
C)
Ineffective tissue perfusion related to low albumin
D) Impaired
skin integrity related to low albumin
Ans: A
Feedback:
Albumin is particularly important for
the maintenance of fluid balance within the vascular system.
Deficiencies nearly always manifest as fluid imbalances. Tissue
oxygenation and skin integrity are not normally affected. Low albumin
does not constitute a risk for infection.
20. An individual has accidentally cut his hand, immediately
initiating the process of hemostasis. Following vasoconstriction, what
event in the process of hemostasis will take place?
A) Fibrin
will be activated at the bleeding site.
B) Platelets will
aggregate at the injury site.
C) Thromboplastin will form a
clot.
D) Prothrombin will be converted to thrombin.
Ans: B
Feedback:
Following vasoconstriction, circulating
platelets aggregate at the site and adhere to the vessel and to one
another, forming an unstable hemostatic plug. Events involved in the
clotting cascade take place subsequent to this initial platelet action.
21. The nurse is providing care for an older adult who has a
hematologic disorder. What age-related change in hematologic function
should the nurse integrate into care planning?
A) Bone marrow in
older adults produces a smaller proportion of healthy, functional
blood cells.
B) Older adults are less able to increase blood cell
production when demand suddenly increases.
C) Stem cells in older
adults eventually lose their ability to differentiate.
D) The
ratio of plasma to erythrocytes and lymphocytes increases with age.
Ans: B
Feedback:
Due to a variety of factors, when an
older person needs more blood cells, the bone marrow may not be able
to increase production of these cells adequately. Stem cell activity
continues throughout the lifespan, although at a somewhat decreased
rate. The proportion of functional cells does not greatly decrease and
the relative volume of plasma does not change significantly.
22. A client’s health history reveals daily consumption of two to
three bottles of wine. The nurse should plan assessments and
interventions in light of the patient’s increased risk for what
hematologic disorder?
A) Leukemia
B) Anemia
C)
Thrombocytopenia
D) Lymphoma
Ans: B
Feedback:
Heavy alcohol use is associated with
numerous health problems, including anemia. Leukemia and lymphoma are
not associated with alcohol use; RBC levels are typically affected
more than platelet levels.
23. A patient’s diagnosis of atrial fibrillation has prompted the
primary care provider to prescribe warfarin (Coumadin), an
anticoagulant. When assessing the therapeutic response to this
medication, what is the nurse’s most appropriate action?
A)
Assess for signs of myelosuppression.
B) Review the patient’s
platelet level.
C) Assess the patient’s capillary refill
time.
D) Review the patient’s international normalized ratio (INR).
Ans: D
Feedback:
The INR and aPTT serve as useful
screening tools for evaluating a patient’s clotting ability and to
monitor the therapeutic effectiveness of anticoagulant medications.
The patient’s platelet level is not normally used as a short-term
indicator of anticoagulation effectiveness. Assessing the patient for
signs of myelosuppression and capillary refill time does not address
the effectiveness of anticoagulants.
24. A patient has been scheduled for a bone marrow biopsy and admits
to the nurse that she is worried about the pain involved with the
procedure. What patient education is most accurate?
A) “You’ll be
given painkillers before the test, so there won’t likely be any
pain?”
B) “You’ll feel some pain when the needle enters your
skin, but none when the needle enters the bone because of the absence
of nerves in bone.”
C) “Most people feel some brief, sharp pain
when the needle enters the bone.”
D) “I’ll be there with you, and
I’ll try to help you keep your mind off the pain.”
Ans: C
Feedback:
Patients typically feel a pressure
sensation as the needle is advanced into position. The actual
aspiration always causes sharp, but brief pain, resulting from the
suction exerted as the marrow is aspirated into the syringe; the
patient should be warned about this. Stating, “I’ll try to help you
keep your mind off the pain” may increase the patient’s fears of pain,
because this does not help the patient know what to expect.
25. A patient is scheduled for a splenectomy. During discharge
education, what teaching point should the nurse prioritize?
A)
The importance of adhering to prescribed immunosuppressant
therapy
B) The need to report any signs or symptoms of infection
promptly
C) The need to ensure adequate folic acid, iron, and
vitamin B12 intake
D) The importance of limiting activity
postoperatively to prevent hemorrhage
Ans: B
Feedback:
After splenectomy, the patient is
instructed to seek prompt medical attention if even relatively minor
symptoms of infection occur. Often, patients with high platelet counts
have even higher counts after splenectomy, which can predispose them
to serious thrombotic or hemorrhagic problems. However, this increase
is usually transient and therefore often does not warrant additional
treatment. Dietary modifications are not normally necessary and
immunosuppressants would be strongly contraindicated.
26. The nurse’s brief review of a patient’s electronic health record
indicates that the patient regularly undergoes therapeutic phlebotomy.
Which of the following rationales for this procedure is most
plausible?
A) The patient may chronically produce excess red
blood cells.
B) The patient may frequently experience a low
relative plasma volume.
C) The patient may have impaired stem
cell function.
D) The patient may previously have undergone bone
marrow biopsy.
Ans: A
Feedback:
Persistently elevated hematocrit is an
indication for therapeutic phlebotomy. It is not used to address
excess or deficient plasma volume and is not related to stem cell
function. Bone marrow biopsy is not an indication for therapeutic phlebotomy.
27. A nurse has participated in organizing a blood donation drive at
a local community center. Which of the following individuals would
most likely be disallowed from donating blood?
A) A man who is 81
years of age
B) A woman whose blood pressure is 88/51 mm
Hg
C) A man who donated blood 4 months ago
D) A woman who
has type 1 diabetes
Ans: B
Feedback:
For potential blood donors, systolic
arterial BP should be 90 to 180 mm Hg, and the diastolic pressure
should be 50 to 100 mm Hg. There is no absolute upper age limit.
Donation 4 months ago does not preclude safe repeat donation and
diabetes is not a contraindication.
28. A nurse at a blood donation clinic has completed the collection
of blood from a woman. The woman states that she feels “lightheaded”
and she appears visibly pale. What is the nurse’s most appropriate
action?
A) Help her into a sitting position with her head lowered
below her knees.
B) Administer supplementary oxygen by nasal
prongs.
C) Obtain a full set of vital signs.
D) Inform a
physician or other primary care provider.
Ans: A
Feedback:
A donor who appears pale or complains of
faintness should immediately lie down or sit with the head lowered
below the knees. He or she should be observed for another 30 minutes.
There is no immediate need for a physician’s care. Supplementary
oxygen may be beneficial, but may take too much time to facilitate
before a syncopal episode. Repositioning must precede assessment of
vital signs.
29. A patient’s low hemoglobin level has necessitated transfusion of
PRBCs. Prior to administration, what action should the nurse
perform?
A) Have the patient identify his or her blood type in
writing.
B) Ensure that the patient has granted verbal consent
for transfusion.
C) Assess the patient’s vital signs to establish
baselines.
D) Facilitate insertion of a central venous catheter.
Ans: C
Feedback:
Prior to a transfusion, the nurse must
take the patient’s temperature, pulse, respiration, and BP to
establish a baseline. Written consent is required and the patient’s
blood type is determined by type and cross match, not by the patient’s
self-declaration. Peripheral venous access is sufficient for blood transfusion.
30. A patient on the medical unit is receiving a unit of PRBCs.
Difficult IV access has necessitated a slow infusion rate and the
nurse notes that the infusion began 4 hours ago. What is the nurse’s
most appropriate action?
A) Apply an icepack to the blood that
remains to be infused.
B) Discontinue the remainder of the PRBC
transfusion and inform the physician.
C) Disconnect the bag of
PRBCs, cool for 30 minutes and then administer.
D) Administer the
remaining PRBCs by the IV direct (IV push) route.
Ans: B
Feedback:
Because of the risk of infection, a PRBC
transfusion should not exceed 4 hours. Remaining blood should not be
transfused, even if it is cooled. Blood is not administered by the IV
direct route.
31. Two units of PRBCs have been ordered for a patient who has
experienced a GI bleed. The patient is highly reluctant to receive a
transfusion, stating, “I’m terrified of getting AIDS from a blood
transfusion.” How can the nurse best address the patient’s
concerns?
A) “All the donated blood in the United States is
treated with antiretroviral medications before it is used.”
B)
“That did happen in some high-profile cases in the twentieth century,
but it is no longer a possibility.”
C) “HIV was eradicated from
the US blood supply in the early 2000s.”
D) “The chances of
contracting AIDS from a blood transfusion in the United States are
exceedingly low.”
Ans: D
Feedback:
The patient can be reassured about the
very low possibility of contracting HIV from the transfusion. However,
it is not an absolute impossibility. Antiretroviral medications are
not introduced into donated blood. The blood supply is constantly
dynamic, due to the brief life of donated blood.
32. A patient is being treated in the ICU after a medical error
resulted in an acute hemolytic transfusion reaction. What was the
etiology of this patient’s adverse reaction?
A) Antibodies to
donor leukocytes remained in the blood.
B) The donor blood was
incompatible with that of the patient.
C) The patient had a
sensitivity reaction to a plasma protein in the blood.
D) The
blood was infused too quickly and overwhelmed the patient’s
circulatory system.
Ans: B
Feedback:
An acute hemolytic reaction occurs when
the donor blood is incompatible with that of the recipient. In the
case of a febrile nonhemolytic reaction, antibodies to donor
leukocytes remain in the unit of blood or blood component. An allergic
reaction is a sensitivity reaction to a plasma protein within the
blood component. Hypervolemia does not cause an acute hemolytic reaction.
33. An interdisciplinary team has been commissioned to create
policies and procedures aimed at preventing acute hemolytic
transfusion reactions. What action has the greatest potential to
reduce the risk of this transfusion reaction?
A) Ensure that
blood components are never infused at a rate greater than 125
mL/hr.
B) Administer prophylactic antihistamines prior to all
blood transfusions.
C) Establish baseline vital signs for all
patients receiving transfusions.
D) Be vigilant in identifying
the patient and the blood component.
Ans: D
Feedback:
The most common causes of acute
hemolytic reaction are errors in blood component labeling and patient
identification that result in the administration of an
ABO-incompatible transfusion. Actions to address these causes are
necessary in all health care settings. Prophylactic antihistamines are
not normally administered, and would not prevent acute hemolytic
reactions. Similarly, baseline vital signs and slow administration
will not prevent this reaction.
34. A patient is receiving a blood transfusion and complains of a new
onset of slight dyspnea. The nurse’s rapid assessment reveals
bilateral lung crackles and elevated BP. What is the nurse’s most
appropriate action?
A) Slow the infusion rate and monitor the
patient closely.
B) Discontinue the transfusion and begin
resuscitation.
C) Pause the transfusion and administer a 250 mL
bolus of normal saline.
D) Discontinue the transfusion and
administer a beta-blocker, as ordered.
Ans: A
Feedback:
The patient is showing early signs of
hypervolemia; the nurse should slow the infusion rate and assess the
patient closely for any signs of exacerbation. At this stage,
discontinuing the transfusion is not necessary. A bolus would worsen
the patient’s fluid overload.
35. A patient lives with a diagnosis of sickle cell anemia and
receives frequent blood transfusions. The nurse should recognize the
patient’s consequent risk of what complication of treatment?
A)
Hypovolemia
B) Vitamin B12 deficiency
C)
Thrombocytopenia
D) Iron overload
Ans: D
Feedback:
Patients with chronic transfusion
requirements can quickly acquire more iron than they can use, leading
to iron overload. These individuals are not at risk for hypovolemia
and there is no consequent risk for low platelet or vitamin B12 levels.
36. A patient is receiving the first of two ordered units of PRBCs.
Shortly after the initiation of the transfusion, the patient complains
of chills and experiences a sharp increase in temperature. What is the
nurse’s priority action?
A) Position the patient in high
Fowler’s.
B) Discontinue the transfusion.
C) Auscultate the
patient’s lungs.
D) Obtain a blood specimen from the patient.
Ans: B
Feedback:
Stopping the transfusion is the first
step in any suspected transfusion reaction. This must precede other
assessments and interventions, including repositioning, chest
auscultation, and collecting specimens.
37. Fresh-frozen plasma (FFP) has been ordered for a hospital
patient. Prior to administration of this blood product, the nurse
should prioritize what patient education?
A) Infection risks
associated with FFP administration
B) Physiologic functions of
plasma
C) Signs and symptoms of a transfusion reaction
D)
Strategies for managing transfusion-associated anxiety
Ans: C
Feedback:
Patients should be educated about signs
and symptoms of transfusion reactions prior to administration of any
blood product. In most cases, this is priority over education relating
to infection. Anxiety may be an issue for some patients, but
transfusion reactions are a possibility for all patients. Teaching
about the functions of plasma is not likely a high priority.
38. The nurse is preparing to administer a unit of platelets to an
adult patient. When administering this blood product, which of the
following actions should the nurse perform?
A) Administer the
platelets as rapidly as the patient can tolerate.
B) Establish IV
access as soon as the platelets arrive from the blood bank.
C)
Ensure that the patient has a patent central venous catheter.
D)
Aspirate 10 to 15 mL of blood from the patient’s IV immediately
following the transfusion.
Ans: A
Feedback:
The nurse should infuse each unit of
platelets as fast as patient can tolerate to diminish platelet
clumping during administration. IV access should be established prior
to obtaining the platelets from the blood bank. A central line is
appropriate for administration, but peripheral IV access (22-gauge or
larger) is sufficient. There is no need to aspirate after the transfusion.
39. Which of the following circumstances would most clearly warrant
autologous blood donation?
A) The patient has type-O
blood.
B) The patient has sickle cell disease or a
thalassemia.
C) The patient has elective surgery pending.
D)
The patient has hepatitis C.
Ans: C
Feedback:
Autologous blood donation is useful for
many elective surgeries where the potential need for transfusion is
high. Type-O blood, hepatitis, sickle cell disease, and thalassemia
are not clear indications for autologous donation.
40. A patient’s electronic health record states that the patient
receives regular transfusions of factor IX. The nurse would be
justified in suspecting that this patient has what diagnosis?
A)
Leukemia
B) Hemophilia
C) Hypoproliferative anemia
D)
Hodgkin’s lymphoma
Ans: B
Feedback:
Administration of clotting factors is
used to treat diseases where these factors are absent or insufficient;
hemophilia is among the most common of these diseases. Factor IX is
not used in the treatment of leukemia, lymphoma, or anemia.
The client receives epoetin alfa (Epogen) subcutaneously, and says to
the nurse, “My doctor said I have anemia. Are there little red blood
cells in that shot?” What are the best responses by the nurse?
Standard Text: Select all that apply.
1. “Your kidney makes more
erythropoietin if it doesn’t get enough oxygen.”
2.
“Erythropoietin also helps your body make hemoglobin.”
3. “This
stimulates your kidney to make more red blood cells.”
4. “It is
similar to a kidney hormone, erythropoietin, and helps your body make
more red blood cells.”
5. “Your kidney makes more erythropoietin
when you have too much fluid in your body.”
Correct Answer: 1,2,4
Rationale 1: Erythropoiesis is regulated
by the kidney hormone, erythropoietin. The primary signal for
increased secretion is a reduction in oxygen reaching the
kidney.
Rationale 2: This hormone reacts with receptors on
hematopoietic stem cells to increase erythrocyte production. It also
stimulates production of hemoglobin.
Rationale 3: Red blood cells
are manufactured in the bone marrow, not in the kidney.
Rationale
4: Epoetin alfa is identical to the natural hormone erythropoietin and
stimulates the production of red blood cells in the same
manner.
Rationale 5: Reduced oxygen, not over-hydration is the
stimulus for the kidney to produce additional erythropoietin.
The nurse is teaching a class on how red blood cell formation is
regulated by the body to a group of clients who have AIDS. The nurse
evaluates that learning has occurred when the clients make which
statements?Standard Text: Select all that apply.
1. “Red blood
cell formation is regulated through chemicals called
colony-stimulating factors that come from white blood cells.”
2.
“Red blood cell formation is regulated through messages from the
hormone, secretin, which is located in the kidney.”
3. “Red blood
cell formation is regulated through specific liver enzymes and a
process called hemochromatosis.”
4. “Red blood cell formation is
regulated through messages from the hormone erythropoietin.”
5.
“Red blood cell formation is regulated through specific transporter
proteins called apolipoprotein A and B.”
Correct Answer: 4
Rationale 1: Colony-stimulating factors affect
white blood cell production.
Rationale 2: Secretin stimulates the
pancreas to release a fluid that neutralizes stomach acid and aids in
digestion; it has nothing to do with red blood cell
formation.
Rationale 3: Hemochromatosis refers to excess iron
accumulation in the body, not to red blood cell
formation.
Rationale 4: Regulation of hematopoiesis occurs
through messages from hormones such as erythropoietin.
Rationale
5: Apolipoprotein refers to a protein found in cholesterol particles;
it has nothing to do with red blood cell formation.
The client receives chemotherapy as therapy for cancer. The physician
orders epoetin alfa (Procrit) subcutaneously. The client asks the
nurse if this drug is also chemotherapy. What is the best response by
the nurse?
1. “No, but it works with your chemotherapy to make it
more effective.”
2. “No, this drug helps to counteract the nausea
and vomiting caused by your chemotherapy.”
3. “No, it will
stimulate your immune system to help you battle the cancer.”
4.
“No, this drug will help prevent anemia that can be caused by your chemotherapy.”
Rationale 4: Epoetin alfa (Procrit) is given to clients undergoing cancer chemotherapy to counteract the anemia caused by antineoplastic agents.
The client receives filgrastim (Neupogen). He asks the nurse, “That
is such a funny name; where do you suppose it comes from?” What is the
best response by the nurse?
1. “It comes from the interleukins it
stimulates; this one stimulates neuocytes.”
2. “It comes from the
blood cell it stimulates; this one stimulates neutrophils.”
3.
“It comes from the stem cells it stimulates, such as
filgrastims.”
4. “It is a complicated process; the drug companies
are secretive about it.”
Rationale 2: Colony-stimulating factors (CSFs) are named according to the types of blood cells that they stimulate. Granulocyte colony-stimulating factor (G-CSF) increases the production of neutrophils, the most common type of granulocyte.
The client is receiving ferrous sulfate (Feosol) for the treatment of
anemia. The nurse has taught the client about this drug and about
anemia. The nurse evaluates that learning has occurred when the client
makes which statement?
1. “My anemia was caused by blood loss
from my ulcer, but there are other causes too.”
2. “My anemia was
caused by drinking too many carbonated beverages with
caffeine.”
3. “There are many causes for anemia; mine was caused
by heart failure and fluid overload.”
4. “I think my anemia
occurred when I started that vegetarian diet.”
Rationale 1: The three categories of blood loss are hemorrhage, increased erythrocyte destruction, and impaired erythrocyte production.
The client had stomach cancer and a surgical removal of his stomach
several years ago. The physician prescribed cyanocobalamin
(Crystamine). The client stopped this drug several months ago. What
will the nurse most likely assess in this client?
1. Memory loss,
numbness in the limbs, and depression
2. A gradual decrease in
red blood cell counts
3. Jaundice, and tarry stools
4. Low
hemoglobin and hematocrit counts
Rationale 1: The most common cause of vitamin B12 deficiency (pernicious anemia) is absence of intrinsic factor, a protein secreted by stomach cells. This protein is required for vitamin B12 to be absorbed from the intestine. Symptoms of pernicious anemia involve the nervous system, and include memory loss, confusion, tingling or numbness in the limbs, and mood disturbances.
The client has chronic alcoholism. He asks the nurse why his doctor
put him on folic acid (Folvite) since he promised the doctor that he
would stop drinking. What is the best response by the nurse?
1.
“You should ask your doctor since you promised him that you would not
drink anymore.”
2. “You have been drinking instead of eating, and
alcohol interferes with folate metabolism in your liver.”
3. “You
need folic acid to make up for the vitamin B12 deficiency that was
caused by your alcoholism.”
4. “You need folic acid because you
have not been compliant with taking your vitamins and attending
Alcoholics Anonymous (AA) meetings.”
Rationale 2: Insufficient folic acid can manifest itself as anemia. This is often observed in chronic alcoholism, since alcoholics consume alcohol instead of eating nutritious foods. Alcohol interferes with folate metabolism in the liver.
The nurse teaches a class on iron-deficiency anemia to a group of
pregnant clients who are all taking ferrous sulfate (Feosol). The
nurse evaluates that additional learning is needed when the clients
make which statement?
1. “Most iron in our bodies is stored on
hemoglobin in the red blood cell.”
2. “Transferrin is a protein
that transports iron to places in our bodies where it is
needed.”
3. “We need extra iron because when our red blood cells
die, all their iron is excreted from the body.”
4. “The most
common cause of nutritional anemia is iron deficiency.”
Rationale 3: After erythrocytes die, nearly all of the iron in their hemoglobin is incorporated into transferrin and recycled for later use.
The physician has prescribed epoetin alfa (Epogen) for the client.
What is the priority assessment by the nurse?
1. The client’s
blood pressure
2. The client’s report of a headache, indicating a
stroke
3. The client’s ability to use the proper injection
techniques for self-administration
4. The client’s hemoglobin and
hematocrit levels
Rationale 1: The most serious adverse effect of epoetin alfa (Epogen) is hypertension, which can raise blood pressure to dangerous levels, and which occurs in as many as 30% of clients receiving the drug.
The physician has ordered filgrastim (Neupogen) intravenously for the
client. What is a priority plan by the nurse prior to administering
this drug?
1. Plan to monitor the client’s ECG readings.
2.
Plan to insert a Foley catheter and monitor urine output.
3. Plan
to administer 10% oxygen during the infusion.
4. Plan to have a
white blood cell (WBC) count drawn every 30 minutes.
Rationale 1: Filgrastim (Neupogen) may cause abnormal ST-segment depression.
The client is pregnant and has been told by her physician that she
needs cyanocobalamin (Nascobal). She asks the nurse, “Will this hurt
my baby?” What is the best response by the nurse?
1. “No, this
medication will not hurt your baby as long as you take it with
ascorbic acid.”
2. “No, this is safe as long as long as you take
it in pill form; it is a Pregnancy Category A drug, which means it is
safe for your baby.”
3. “No, this medication will not hurt your
baby as long as you take the pills only in the third
trimester.”
4. “No, this is safe in either pill or injectable
form; it is a Pregnancy Category A drug which means it is safe for
your baby.”
Rationale 2: Cyanocobalamin (Nascobal), oral formulation, is a Pregnancy Category A drug, but it is a Pregnancy Category C when used parenterally.
The client complains of constipation while receiving ferrous sulfate
(Feosol). What is the best plan by the nurse to assist the client in
resolving this common side effect?
1. Plan to teach the client
about which laxatives are the safest to use.
2. Plan to teach the
client to increase fluids and high-fiber foods in the diet.
3.
Plan to teach the client to self-administer Fleets enemas.
4.
Plan to teach the client to increase exercise.
Rationale 2: Constipation is a common side effect of ferrous sulfate; therefore, an increase in dietary fiber may be indicated.
The client is receiving chemotherapy for cancer. The physician has
prescribed oprelvekin (Neumega). The nurse has completed medication
education and evaluates it as effective when the client makes which
statement?
1. “This medication will help my chemotherapy work
better.”
2. “This medication will help increase my platelet
count.”
3. “This medication will help me regain the weight I have
lost.”
4. “This medication will help increase my red blood cell count.”
Rationale 2: Oprelvekin (Neumega) is used to stimulate the production of platelets in clients who are at risk for thrombocytopenia caused by cancer chemotherapy.
The client calls the nurse and is very frantic. “I think something is
wrong! My stools are black and they have never been this color
before!” The client is receiving ferrous sulfate (Feosol). What is the
best response by the nurse?
1. “This is an expected side effect
of ferrous sulfate (Feosol); it is okay.”
2. “This sounds
serious; you may have started bleeding again.”
3. “Do you have
hemorrhoids? That could be the problem.”
4. “I will speak with
your doctor and call you right back.”
Rationale 1: Ferrous sulfate (Feosol) will turn stools a harmless, dark green or black color; this is an expected side effect of the medication.
The process for regulating hematopoiesis occurs via
1. white
bone marrow.
2. hematopoietic stem cell.
3.
hormones.
4. essential vitamins and nutrients.
Correct Answer: 3
Rationale 1: Hematopoiesis occurs primarily in
red bone marrow.
Rationale 2: The process of hematopoiesis begins
with a stem cell.
Rationale 3: Regulation of hematopoiesis occurs
through messages from hormones.
Rationale 4: Hematopoiesis occurs
primarily in red bone marrow, and requires B vitamins, vitamin C,
copper, iron, and other nutrients.
Colony-stimulating factors (CSFs) are named according to
1. type
of blood cell stimulated.
2. type of hormone secreted.
3.
type of homeostatic control.
4. type of stem cell stimulated.
Correct Answer: 1
Rationale 1: CSFs are named according to types
of blood cells stimulated.
Rationale 2: The type of hormone is
responsible for hematopoiesis regulation.
Rationale 3:
Homeostatic control is influenced by hormones and growth
factors.
Rationale 4: The type of stem cell stimulated is
responsible for hematopoiesis.
In monitoring clients receiving hematopoietic agents, it is most
important for the nurse to monitor for
1. thromboembolus.
2.
TIA (transient ischemic attack).
3. MI (myocardial
infarction).
4. stroke.
Correct Answer: 1
Rationale 1: Clients are at greater risk for
thrombolitic disease, which can result in MI, stroke, and
TIA.
Rationale 2: Transient ischemic attack can occur as a result
of thromboembolic disease.
Rationale 3: Myocardial infarction can
occur as a result of thromboembolic disease.
Rationale 4: Stroke
can occur as a result of thromboembolic disease.
To decrease gastric irritation, anti-anemia medications, such as
ferrous sulfate (Ferosol), should be taken with
1. milk.
2.
other medications, such as calcium.
3. orange juice.
4. food.
Correct Answer: 4
Rationale 1: Taking with milk would decrease
absorption.
Rationale 2: Several medications can increase or
decrease absorption.
Rationale 3: Taking with orange juice can
increase gastric irritations.
Rationale 4: Taking iron
medications with food will decrease gastric irritation.
The mechanism of action of colony-stimulating factors, such as
filgrastim (Neupogen), is to
1. increase neutrophil
production.
2. supplement iron in the body.
3. replace
vitamin B12 factor.
4. increase erythrocyte production.
Correct Answer: 1
Rationale 1: The primary mechanism of action
is to increase neutrophil production and phagocytosis in chemotherapy
clients.
Rationale 2: Anti-anemic iron supplements increase iron
in the body.
Rationale 3: Anti-anemic vitamin supplements
increase B12 in the body.
Rationale 4: Hematopoietic growth
factors increase erythrocytes in the bone marrow.
Per classification of anemias, the morphology for pernicious anemia
or folate-deficiency anemia results in
1.
hematocytic–hematochromic erythrocytes.
2. microcytic–hypochromic
erythrocytes.
3. macrocytic–normochromic erythrocytes.
4.
normocytic–normochromic erythrocytes.
Correct Answer: 3
Rationale 1: Hematocytic–hematochromic
erythrocytes do not classify anemias.
Rationale 2:
Microcytic–hypochromic erythrocytes classify iron-deficiency anemia or
thalassemia.
Rationale 3: Macrocytic–normochromic erythrocytes
classify pernicious and folate-deficiency anemia.
Rationale 4:
Normocytic–normochromic erythrocytes classify aplastic, hemorrhagic,
sickle-cell, and hemolytic anemia.
A client is to receive darbepoetin alfa (Aranesp) adjunctive
medication during chemotherapy. The client says, “Not another drug.
Why do I need this one?” How should the nurse respond? Standard Text:
Select all that apply.
1. “I know you are tired of drugs, but
this is just one more.”
2. “This drug will help you grow red
blood cells.”
3. “This drug will help keep you from getting
infections.”
4. “This is an erythropoiesis-stimulating
factor.”
5. “This drug will help you get more oxygen around to
your tissues so you feel better.”
Correct Answer: 2,5
Rationale 1: This response does not answer
the client’s question.
Rationale 2: Darbepoetin alfa (Aranesp) is
an erythropoiesis-stimulating factor.
Rationale 3: Darbepoetin
alfa (Aranesp) does not increase immunity.
Rationale 4: The nurse
should explain the medication in terms the client can
understand.
Rationale 5: Darbepoetin alfa (Aranesp) stimulates
production of red blood cells which carry oxygen. Getting additional
oxygen to the tissues helps the client feel better.
A client has been treated with an erythropoiesis-stimulating factor.
Which client assessment would the nurse interpret as indicating the
goal of this treatment has been reached? Standard Text: Select all
that apply.
1. The client’s hemoglobin values have risen.
2.
The client reports less shortness of breath on exertion.
3. The
client has not had an episode of epistaxis in over three
weeks.
4. The client reports enjoying a walk with family for the
first time in months.
5. The client has not had a fever since
treatment began.
Correct Answer: 1,2,4
Rationale 1: The purpose of this therapy
is to increase red blood cells which would increase
hemoglobin.
Rationale 2: Since the client has more RBCs, more
oxygen can be carried to tissues.
Rationale 3: This drug supports
RBC production, not platelet production.
Rationale 4: Increase in
activity level indicates treatment success.
Rationale 5: This
treatment supports red blood cell production, not white blood cell production.
A client is scheduled to have chemotherapy Thursday at 9 a.m.
Filgrastim (Neupogen) has also been ordered. The nurse should plan
which dosing time for the Neupogen? Standard Text: Select all that
apply.
1. No later than 9 a.m. on Wednesday
2. At the time
of the chemotherapy infusion
3. Immediately following the
chemotherapy
4. No earlier than 9 a.m. Friday
5. Immediately
before the chemotherapy
Correct Answer: 1,4
Rationale 1: Neupogen should be given at
least 24 hours before chemotherapy.
Rationale 2: The
effectiveness of the Neupogen will be diminished by the
chemotherapy.
Rationale 3: The effectiveness of the Neupogen will
be diminished by the chemotherapy.
Rationale 4: Neupogen should
be given no earlier than 24 hours after chemotherapy.
Rationale
5: The effectiveness of the Neupogen will be diminished by the chemotherapy.
A client’s blood work shows an anemia that was not present at the
last clinic visit 6 months ago. Which questions should the nurse ask
this client? Standard Text: Select all that apply.
1. “Have you
had a significant dietary change in the last 6 months?”
2. “Do
you handle chemicals in your new job?”
3. “Have your stools
changed in appearance?”
4. “Have you been eating more
carbohydrates than usual?”
5. “Are your menstrual periods heavier
than normal for you?”
Correct Answer: 1,2,3,5
Rationale 1: Dietary changes may
significantly influence production of red blood cells.
Rationale
2: Chemicals can cause RBC destruction.
Rationale 3: Change to
dark tarry stool, red stools, or much looser stools could indicate
blood loss.
Rationale 4: There is no connection between
carbohydrate ingestion and anemia.
Rationale 5: Heavy menstrual
flow is a leading cause of blood loss anemia in women.
A nurse is preparing to administer ferrous sulfate IM to a client
with anemia. What should the nurse consider when giving this
injection? Standard Text: Select all that apply.
1. Give the
injection in the deltoid muscle.
2. Iron is best absorbed if
given subcutaneously.
3. Iron is irritating to the
tissues.
4. The z-track method should be used.
5. Iron
preparations should be administered through a needle gauge 16 or larger.
Correct Answer: 3,4
Rationale 1: The injection should be given
deep IM in a larger muscle.
Rationale 2: Iron should be given
deep IM.
Rationale 3: Iron is irritating to
tissues.
Rationale 4: Z-track injection reduces leakage into the
tissues and is the preferred method of IM injection of
iron.
Rationale 5: There is no indication of need to use a large
diameter needle for injection.