CH 41, 42 – hematology NCLEX review – Flashcards
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p. 873, Safe and Effective Care Environment Which laboratory value in a client with sickle cell disease does the nurse report immediately to the health care provider? A. Hematocrit 24% B. Hemoglobin S (HbS) 78% C. Platelet count 260,000/mm3 D. White blood cell (WBC) count 20,000/mm3
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ANS: D Rationale: Clients with sickle cell disease are usually anemic, and the hematocrit level is not critical at this time. An HbS level of 78% is an expected finding and not one that the health care provider must be informed about at this time. The platelet count is lower than normal but is not low enough to lead to uncontrolled bleeding. The WBCs are elevated. Although most clients with SCD do have a somewhat elevated WBC level, this count is too high and indicates the presence of an acute infection. The health care provider must be notified immediately and the proper interventions instituted.
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p. 875, Psychosocial Integrity A woman whose hemoglobin S levels are less than 1% has a brother with sickle cell disease (SCD) and both parents have been diagnosed as carriers for the disorder. She asks what her risks are of having a child with sickle cell disease. What is the nurse's best response? A. "Because you do not have the trait, you cannot have a child with SCD regardless of your partner's sickle cell status." B. "Because both your parents have the trait, it is possible for you to have a child with SCD if your partner actually has the disease." C. "Because your brother actually has SCD, the risk for your children having SCD is 50% with each pregnancy." D. "Because you are a woman, your daughters will each have a 50% risk for having the disease, and all of your sons will be carriers of the trait."
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ANS: A Rationale: SCD is an autosomal recessive genetic disorder. This woman does not have SCD or a sickle cell trait, as evidenced by her HbS levels being less than 1%. Therefore regardless of her partner's sickle cell status, she will not have a child with actual SCD. However, if her partner is a carrier, any child she has with this partner has a 50% risk of having a sickle cell trait. If her partner has SCD, any child she has will be a carrier of sickle cell trait.
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p. 878, Health Promotion and Maintenance Which statement made by a client with folic acid deficiency anemia indicates to the nurse a correct understanding of self-management for this health problem? A. "If my fingers and toes become numb, I will notify my health care provider immediately." B. "I will stop playing contact sports or any activity that increases my risk for injury." C. "My diet now includes more carrots, cauliflower, and apples." D. "I have stopped drinking alcohol completely."
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ANS: D Rationale: A major cause of folic acid deficiency is chronic alcoholism. Stopping all intake of alcohol helps increase folic acid levels. A diet with good intake of green, leafy vegetables, liver, yeast, citrus fruits, dried beans, and nuts helps replace the deficient nutrient. Folic acid deficiency does not cause neurologic symptoms and does not reduce platelet levels. Therefore the risk for bleeding is not increased and the client should not have peripheral neuropathy from this problem.
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p. 881, Health Promotion and Maintenance A client newly diagnosed with acute leukemia asks why he is at such extreme risk for infection when his white blood cell count is so high. What is the nurse's best response? A. "Even though you have many white blood cells, they are too immature to fight infection." B. "For now, your risk is low; however, when the chemotherapy begins, your risk for infection will be high." C. "These white blood cells are cancerous and live longer than normal white blood cells, so they are too old to fight infection." D. "It is not the white blood cells that provide protection; it is the red blood cells, which are very low in your blood right now."
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ANS: A Rationale: For clients who understand that white blood cells are a great protection against infection, being at great risk for infection even when WBC counts are sometimes ten times normal is confusing. These are leukemic cells that overgrow at a very immature level. Therefore even though there can be huge numbers of circulating WBCs, these cells are so immature that they are nonfunctional. In addition, the heavy production of immature leukemic cells prevents normal WBCs, RBCs, and platelets from forming and maturing into functional cells.
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p. 885, Health Promotion and Maintenance Which precaution is most important for the nurse to teach a client with leukemia to prevent an infection by autocontamination? A. Take antibiotics exactly as prescribed. B. Perform mouth care three times daily. C. Avoid the use of pepper and raw foods. D. Report any burning on urination immediately.
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ANS: B Rationale: Autocontamination is the overgrowth of the client's own normal flora or the translocation of his or her normal flora from its normal location to a different one. Performing frequent mouth care can reduce the number of normal flora organisms in the mouth and decrease the risk for developing an infection from autocontamination. Taking antibiotics does not prevent autocontamination, nor does reporting symptoms of an infection. Avoiding exposure to environmental organisms does not prevent autocontamination.
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p. 891, Physiological Integrity Six weeks after hematopoietic stem cell transplantation for leukemia, the client's white blood cell (WBC) count is 8200/mm3. What is the nurse's best action in view of this laboratory result? A. Notify the health care provider immediately. B. Assess the client for other symptoms of infection. C. Document the laboratory report as the only action. D. Remind the client to avoid crowds and people who are ill.
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ANS: C Rationale: The WBC count is now within the normal range (5000 to 10,000/mm3) and is an indicator of successful engraftment. The client is not at any particular risk for infection at this time, nor is there reason to believe an infection is present. (At any post-transplantation check-up, the client is assessed for infection.)
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p. 896, Health Promotion and Maintenance Which precaution is most important for the nurse to teach a client with autoimmune thrombocytopenic purpura who is receiving corticosteroid therapy to control the disease? A. "Avoid contact sports and any activity that could cause injury." B. "Report any rash to your health care provider immediately." C. "Be sure to drink at least 3 liters of water daily." D. "Take a low-dose aspirin daily with food."
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ANS: A Rationale: The client has too few functional platelets to form clots in response to injury and is at great risk for bleeding. The corticosteroids also make tissues and blood vessels more fragile. Aspirin decreases platelet aggregation and should not be taken by anyone with this disorder. Although reporting a rash and drinking at least 3 liters of water daily are positive actions, they are not the most important precautions for this client to take.
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p. 901, Physiological Integrity Which assessment is most important for the nurse to perform for the client receiving one unit of packed red blood cells from an autologous donation? A. Temperature B. Blood pressure C. Oxygen saturation D. IV site for hives
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ANS: A Rationale: In an autologous blood transfusion, the client receives his or her own blood components. Therefore the chances for an incompatibility type reaction do not exist. The main problems that can come from autologous transfusion are fluid overload and infection from blood contamination during the collection, storage, or infusion processes. Fluid overload is very unlikely when only one unit is being transfused. Contamination and infection are just as likely with an autologous transfusion as they are with a transfusion of donated blood products. The most important assessment is for signs of infection, including temperature.
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p. 875, Safety; Patient-Centered Care A 23-year-old African-American woman who has a history of sickle cell disease is brought to the emergency department. She reports joint and back pain that is becoming worse rapidly. She rates her pain as a 9 on a 0-to-10 scale. She is pale, and her vital signs are normal except for a temperature of 101.5 F (38.6 C). She tells you that she had sexual intercourse for the first time 2 days ago. She also says that she now has pain just above the pubic bone during and after urination and that the urine burns. 1. What questions related to pain would you ask this patient? 2. What drug or drugs for pain would you expect this patient to receive and by which route? 3. What diagnostic tests would you expect to be requested for this patient? 4. What nursing assessments would be most important for you to make at this time? 5. What factor or factors could have triggered this crisis episode?
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1. Ask the patient what she has been doing at home to relieve either the back pain or the pelvic pain. Ask her what type of medication has provided pain relief for her in the past and what dose of the medication is usually required for acceptable pain relief. Determine whether she has taken any analgesics at home, what they were, and the time and amount of the last dose. 2. Because she is having very severe pain, she should receive morphine and hydromorphone (Dilaudid) first by IV bolus and then on a routine schedule or by infusion pump using patient-controlled analgesia. 3. The manifestations of pain above the pubic bone and burning on urination suggest some type of urinary tract infection, at least cystitis. Her back pain may be related to a kidney infection or be part of the crisis. Either way, she will probably have a urinalysis and urine culture. A CBC with differential is needed to support a possible diagnosis of infection. This test will also indicate how anemic she may be. A blood culture is needed to determine whether sepsis is present. A bilirubin level can indicate how rapidly her RBCs are being destroyed. If she does not have a sickle cell hemoglobin electrophoresis on record, this may be requested to determine what percentage of her cells have hemoglobin S and hemoglobin F. This information will be useful in long-term management of the disease. 4.Assess her circulation to distal extremities. Determine her breathing pattern and heart rate and rhythm. Discuss her joint pain. Ask which joints are involved and whether this is a new development. Ask her whether she used contraception protection for her first sexual encounter and if there is any possibility she may be pregnant. When her pain has been reduced, determine what she knows about the disorder and its management. 5.An infection is the most likely contributing factor to this episode.
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p. 888, Patient-Centered Care; Teamwork and Collaboration The patient is a 32-year-old woman with acute lymphocytic leukemia. After successful induction therapy, she received a bone marrow transplant with cells donated by her only sibling, a 27-year-old sister. The first transplant failed to engraft. The patient was transplanted a second time with cells donated by the same sister. It is now 5 weeks after the second transplant and there are no indications of engraftment. A third transplant is planned but the sister is reluctant to donate again because she is worried that bone marrow donation may decrease her chances of ever becoming pregnant. The parents of the two sisters are astounded that the younger daughter appears willing to let her sister die rather than go through another bone marrow harvesting procedure. 1. How should the patient, parents, and donating sister be approached and by whom? 2. Legally, should this sister be asked to donate again? 3. In what way does bone marrow harvesting affect fertility?
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1. The parents and patient should be reminded that the bone marrow harvesting procedures are quite uncomfortable for the sister, and both the procedure and anesthesia present a potential risk to her health. Remind the parents that if the donor sister really did not care about the patient, she would not have agreed to donate at all. It is possible that the donor sister feels that her previous suffering through the harvesting procedures has been wasted because the graft did not take. In addition, if the patient, parents, and others on the health care team just assume that she will donate again, the donor sister may be feeling unappreciated and less important to her parents than the sister with leukemia. The sister should be interviewed by a counselor not involved in the transplant issue to determine her real concerns and to act as the donor's advocate. Clergy may also be helpful here. 2. At most stem cell transplant centers, the issue of repeated harvesting is raised before the donor agrees to donate. Usually, the informed consent statement indicates that the donor is willing to participate until a graft is successful. Legally, the sister has an obligation; however, it is wrong to coerce anyone at any stage of this situation. The donor sister should be reminded of the complete and accurate facts regarding her own health and future fertility. Even though time is running out, the option to harvest stem cells by plasma pheresis is still an option and one that the donor sister may find more acceptable than bone marrow harvesting. 3.Bone marrow harvesting and pheresis appear to have no known long-term effects on fertility. The donor may feel tired or be anemic for several weeks after donation, but these are temporary effects.
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p. 863, Physiological Integrity Which clinical manifestation reported by a client suggests to the nurse that anemia is a possibility? A. Difficulty sleeping B. Cold hands and feet C. Chronic headaches D. Shortness of breath
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ANS: D Rationale: Shortness of breath is very common with anemia because the blood is not efficient at providing enough oxygen. Therefore to maintain adequate oxygenation to tissues, the person must increase his or her respiratory rate. Although cold hands/feet and headaches are associated with anemia, these manifestations are not specific enough to suggest anemia.
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