CH 41, 42 – hematology NCLEX review – Flashcards

ANS: B Rationale: Almost every step in the blood-clotting cascade requires activated platelets to aggregate. The substance thromboxane activates platelets, making them stick together. Aspirin disrupts the enzyme cyclooxygenase (COX), which produces thromboxane. Therefore with less thromboxane present, fewer platelets are activated and blood clotting is reduced.

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.

ANS: A Rationale: All of these test results are in the low to low-normal range. However, the most abnormal result is the red blood cell count. The normal red blood cell range is 4.2 to 6.1 million/mm3. This client's value is dangerously below normal.

1. Going back to work after the biopsy is not a good idea and will be expressly forbidden by the clinician who performs the biopsy. A bone marrow biopsy is an uncomfortable (and often painful) procedure for which many people receive sedation or a mind-altering anesthetic. These drugs would preclude her going back to work after the biopsy. In addition, there is a high risk for bleeding after the biopsy, especially with a low platelet count. Instructions are to rest for at least 24 hours and to avoid any activity that could result in trauma to the site (working on a nursing unit is a risk for bumping the site). She will need to apply ice packs to the site and inspect it for the presence of active bleeding or bruising every 2 hours for the first 24 hours. 2. Explain why or why not. Delaying the biopsy is not a good idea. She has many manifestations of acute leukemia, which is a very serious and life-threatening illness. Her best chances for survival are with an early diagnosis and treatment initiation. In addition, with a low platelet count and an abnormal white blood cell count, she is at a greatly increased risk for uncontrollable bleeding after any trauma and is at an increased risk for infection. Working in a hospital setting increases the risk for both these events. 3.She should stop taking the aspirin now and be sure to tell the person planning the biopsy that she has been taking aspirin. The biopsy may need to be delayed for 2 to 3 days to reduce the bleeding risk associated with aspirin use.

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.

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.

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.

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.

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.

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.)

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.

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.

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.

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.

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.