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Chapter 30: Hematologic Problems Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 1. A 62-year old man with chronic anemia is experiencing increased fatigue and occasional

palpitations at rest. The nurse would expect the patient’s laboratory test findings to include an RBC count of 4,500,000/mL. a hematocrit (Hct) value of 38%. normal red blood cell (RBC) indices. a hemoglobin (Hgb) of 8.6 g/dL (86 g/L).

a. b. c. d.

ANS: D

The patient’s clinical manifestations indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal. DIF: Cognitive Level: Understand (comprehension) REF: 607 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. Which menu choice indicates that the patient understands the nurse’s teaching about

recommended dietary choices for iron-deficiency anemia? c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice

a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese ANS: A

Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia. DIF: Cognitive Level: Apply (application) REF: 610 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 3. A patient who is receiving methotrexate for severe rheumatoid arthritis develops a

megaloblastic anemia. The nurse will anticipate teaching the patient about increasing oral intake of a. iron. c. cobalamin (vitamin B12). b. folic acid. d. ascorbic acid (vitamin C). ANS: B

Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia. DIF: Cognitive Level: Apply (application) REF: 612 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 4. A 52-yr-old patient has a new diagnosis of pernicious anemia. The nurse determines that the

patient understands the teaching about the disorder when the patient states, a. “I need to start eating more red meat and liver.” b. “I will stop having a glass of wine with dinner.” c. “I could choose nasal spray rather than injections of vitamin B12.” d. “I will need to take a proton pump inhibitor such as omeprazole (Prilosec).”

ANS: C

Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin. DIF: Cognitive Level: Apply (application) REF: 612 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 5. An appropriate nursing intervention for a hospitalized patient with severe hemolytic anemia is

to a. b. c. d.

provide a diet high in vitamin K. alternate periods of rest and activity. teach the patient how to avoid injury. place the patient on protective isolation.

ANS: B

Nursing care for patients with anemia should alternate periods of rest and activity to encourage activity without causing undue fatigue. There is no indication that the patient has a bleeding disorder, so a diet high in vitamin K or teaching about how to avoid injury is not needed. Protective isolation might be used for a patient with aplastic anemia, but it is not indicated for hemolytic anemia. DIF: Cognitive Level: Apply (application) REF: 608 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 6. Which patient statement to the nurse indicates a need for additional instruction about taking

oral ferrous sulfate? “I will call my health care provider if my stools turn black.” “I will take a stool softener if I feel constipated occasionally.” “I should take the iron with orange juice about an hour before eating.” “I should increase my fluid and fiber intake while I am taking iron tablets.”

a. b. c. d.

ANS: A

It is normal for the stools to appear black when a patient is taking iron, and the patient should not call the health care provider about this. The other patient statements are correct. DIF: Cognitive Level: Apply (application) REF: 609 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 7. Which collaborative problem will the nurse include in a care plan for a patient admitted to the

hospital with idiopathic aplastic anemia? Potential complication: seizures Potential complication: infection Potential complication: neurogenic shock Potential complication: pulmonary edema

a. b. c. d.

ANS: B

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

DIF: Cognitive Level: Apply (application) REF: 614 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 8. It is important for the nurse providing care for a patient with sickle cell crisis to a. limit the patient’s intake of oral and IV fluids. b. evaluate the effectiveness of opioid analgesics. c. encourage the patient to ambulate as much as tolerated. d. teach the patient about high-protein, high-calorie foods. ANS: B

Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized. DIF: Cognitive Level: Apply (application) REF: 618 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 9. Which statement by a patient indicates good understanding of the nurse’s teaching about

prevention of sickle cell crisis? “Home oxygen therapy is frequently used to decrease sickling.” “There are no effective medications that can help prevent sickling.” “Routine continuous dosage narcotics are prescribed to prevent a crisis.” “Risk for a crisis is decreased by having an annual influenza vaccination.”

a. b. c. d.

ANS: D

Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises. DIF: Cognitive Level: Apply (application) REF: 617 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 10. Which instruction will the nurse plan to include in discharge teaching for a patient admitted

with a sickle cell crisis? Take a daily multivitamin with iron. Limit fluids to 2 to 3 quarts per day. Avoid exposure to crowds when possible. Drink only two caffeinated beverages daily.

a. b. c. d.

ANS: C

Exposure to crowds increases the patient’s risk for infection, the most common cause of sickle cell crisis. There is no restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended. DIF: Cognitive Level: Apply (application) REF: 617 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

11. The nurse notes scleral jaundice in a patient being admitted with hemolytic anemia. The nurse

will plan to check the laboratory results for the a. Schilling test. b. bilirubin level.

c. gastric analysis. d. stool occult blood.

ANS: B

Jaundice is caused by the elevation of bilirubin level associated with red blood cell hemolysis. The other tests would not be helpful in monitoring or treating a hemolytic anemia. DIF: Cognitive Level: Apply (application) REF: 615 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 12. A patient who has been receiving IV heparin infusion and oral warfarin (Coumadin) for a deep

vein thrombosis (DVT) is diagnosed with heparin-induced thrombocytopenia (HIT) when the platelet level drops to 110,000/µL. Which action will the nurse include in the plan of care? a. Prepare for platelet transfusion. b. Discontinue the heparin infusion. c. Administer prescribed warfarin (Coumadin). d. Use low-molecular-weight heparin (LMWH). ANS: B

All heparin is discontinued when HIT is diagnosed. The patient should be instructed to never receive heparin or LMWH. Warfarin is usually not given until the platelet count has returned to 150,000/µL. The platelet count does not drop low enough in HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis. DIF: Cognitive Level: Apply (application) REF: 622 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 13. An expected action by the nurse caring for a patient who has an acute exacerbation of

polycythemia vera is to a. place the patient on bed rest. b. administer iron supplements.

c. avoid use of aspirin products. d. monitor fluid intake and output.

ANS: D

Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis. Iron is contraindicated in patients with polycythemia vera. DIF: Cognitive Level: Apply (application) REF: 621 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 14. Which intervention will be included in the nursing care plan for a patient with immune

thrombocytopenic purpura? Assign the patient to a private room. Avoid intramuscular (IM) injections. Use rinses rather than a soft toothbrush for oral care. Restrict activity to passive and active range of motion.

a. b. c. d.

ANS: B

IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room. DIF: Cognitive Level: Apply (application) REF: 622 TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment 15. Which laboratory result will the nurse expect to show a decreased value if a patient develops

heparin-induced thrombocytopenia (HIT)? Prothrombin time Erythrocyte count Fibrinogen degradation products Activated partial thromboplastin time

a. b. c. d.

ANS: D

Platelet aggregation in HIT causes neutralization of heparin, so the activated partial thromboplastin time will be shorter, and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT. DIF: Cognitive Level: Understand (comprehension) REF: 622 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 16. The nurse is caring for a patient with type A hemophilia being admitted to the hospital with

severe pain and swelling in the right knee. The nurse should apply heat to the knee. immobilize the knee joint. assist the patient with light weight bearing. perform passive range of motion to the knee.

a. b. c. d.

ANS: B

The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range of motion (ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are started. DIF: Cognitive Level: Apply (application) REF: 626 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 17. A young adult who has von Willebrand disease is admitted to the hospital for minor knee

surgery. The nurse will review the coagulation survey to check the c. thrombin time. d. prothrombin time.

a. platelet count. b. bleeding time. ANS: B

The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease. DIF: Cognitive Level: Understand (comprehension) REF: 626 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 18. A routine complete blood count for an active older man indicates possible myelodysplastic

syndrome. The nurse will plan to teach the patient about a. blood transfusion.

b. bone marrow biopsy. c. filgrastim (Neupogen) administration. d. erythropoietin (Epogen) administration. ANS: B

Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy. DIF: Cognitive Level: Apply (application) REF: 634 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 19. Which action will the admitting nurse include in the care plan for a patient who has

neutropenia? Avoid intramuscular injections. Check temperature every 4 hours. Omit fruits or vegetables from the diet. Place a “No Visitors” sign on the door.

a. b. c. d.

ANS: B

The earliest sign of infection in a neutropenic patient is an elevation in temperature. Although unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a “no visitors” policy is not needed. DIF: Cognitive Level: Apply (application) REF: 632 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 20. Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is

effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? c. Total lymphocyte count d. Absolute neutrophil count

a. Platelet count b. Reticulocyte count ANS: D

Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim. DIF: Cognitive Level: Apply (application) REF: 634 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 21. A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned

chemotherapy will be worth undergoing. Which response by the nurse is appropriate? a. “If you do not want to have chemotherapy, other treatment options include stem

cell transplantation.” b. “The side effects of chemotherapy are difficult, but AML frequently goes into remission with chemotherapy.” c. “The decision about treatment is one that you and the doctor need to make rather than asking what I would do.” d. “You don’t need to make a decision about treatment right now because leukemias

in adults tend to progress slowly.” ANS: B

This response uses therapeutic communication by addressing the patient’s question and giving accurate information. The other responses either give inaccurate information or fail to address the patient’s question, which will discourage the patient from asking the nurse for information. DIF: Cognitive Level: Apply (application) REF: 636 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 22. A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a

transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient? a. Infuse the PRBCs slowly over 4 hours. b. Transfuse only leukocyte-reduced PRBCs. c. Administer the scheduled diuretic before the transfusion. d. Give the PRN dose of antihistamine before the transfusion. ANS: B

TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI. DIF: Cognitive Level: Apply (application) REF: 651 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 23. A patient who has acute myelogenous leukemia (AML) is considering treatment with a

hematopoietic stem cell transplant (HSCT). The best approach for the nurse to assist the patient with a treatment decision is to a. discuss the need for insurance to cover post-HSCT care. b. ask whether there are questions or concerns about HSCT. c. emphasize the positive outcomes of a bone marrow transplant. d. explain that a cure is not possible with any treatment except HSCT. ANS: B

Offering the patient an opportunity to ask questions or discuss concerns about HSCT will encourage the patient to voice concerns about this treatment and will allow the nurse to assess whether the patient needs more information about the procedure. Treatment of AML using chemotherapy is another option for the patient. It is not appropriate for the nurse to ask the patient to consider insurance needs in making this decision. DIF: Cognitive Level: Apply (application) REF: 635 TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity 24. Which action will the nurse include in the plan of care for a patient admitted with multiple

myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation.

ANS: A

A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient’s calcium level and are not used. DIF: Cognitive Level: Apply (application) REF: 646 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 25. An appropriate nursing intervention for a patient with non-Hodgkin’s lymphoma whose

platelet count drops to 18,000/µL during chemotherapy is to check all stools for occult blood. encourage fluids to 3000 mL/day. provide oral hygiene every 2 hours. check the temperature every 4 hours.

a. b. c. d.

ANS: A

Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated. DIF: Cognitive Level: Apply (application) REF: 644 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 26. A patient who has acute myelogenous leukemia develops an absolute neutrophil count of

850/µL while receiving outpatient chemotherapy. Which action by the outpatient clinic nurse is most appropriate? a. Discuss the need for hospital admission to treat the neutropenia. b. Teach the patient to administer filgrastim (Neupogen) injections. c. Plan to discontinue the chemotherapy until the neutropenia resolves. d. Order a high-efficiency particulate air (HEPA) filter for the patient’s home. ANS: B

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