Chapter 40 Care of Patients with Hematologic Problems PDF

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Chapter40:CareofPatientswithHematologicProblems MULTIPLECHOICE 1.Anursecaringforaclientwithsicklecelldisease(SCD)reviewstheclientslaboratorywork.Whichfinding shouldthenursereporttotheprovider? a.Creatinine:2.9mg/dL b.Hematocrit:30% c.Sodium:147mEq/L d.Whitebloodcellcount:12,000/mm3 ANS:A Anelevatedcreatinineindicateskidneydamage,whichoccursinSCD.Ahematocritlevelof30%isan expectedfinding,asisaslightlyelevatedwhitebloodcellcount.Asodiumlevelof147mEq/L,although slightlyhigh,isnotconcerning. DIF:Applying/ApplicationREF:811 KEY:Hematologicsystem|laboratoryvalues|anemias MSC:IntegratedProcess:CommunicationandDocumentation NOT:ClientNeedsCategory:PhysiologicalIntegrity:ReductionofRiskPotential 2.Aclienthospitalizedwithsicklecellcrisisfrequentlyasksforopioidpainmedications,oftenshortlyafter receivingadose.Thenursesontheunitbelievetheclientisdrugseeking.Whentheclientrequestspain medication,whatactionbythenurseisbest? a.Givetheclientpainmedicationifitistimeforanotherdose. b.Instructtheclientnottorequestpainmedicationtooearly. c.Requesttheproviderleaveaprescriptionforaplacebo. d.Telltheclientitistooearlytohavemorepainmedication. ANS:A Clientswithsicklecellcrisisoftenhaveseverepainthatismanagedwithupto48hoursofIVopioid analgesics.Eveniftheclientisaddictedanddrugseeking,heorsheisstillinextremepain.Iftheclientcan receiveanotherdoseofmedication,thenurseshouldprovideit.Theotheroptionsarejudgmentalanddonot addresstheclientspain.Givingplacebosisunethical. DIF:Applying/ApplicationREF:811 KEY:Hematologicsystem|anemias|pain|caring MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation 3.Aclientinsicklecellcrisisisdehydratedandintheemergencydepartment.ThenurseplanstostartanIV. Whichfluidchoiceisbest? a.0.45%normalsaline b.0.9%normalsaline c.Dextrose50%(D50) d.LactatedRingerssolution ANS:A Becauseclientsinsicklecellcrisisareoftendehydrated,thefluidofchoiceisahypotonicsolutionsuchas 0.45%normalsaline.0.9%normalsalineandlactatedRingerssolutionareisotonic.D50ishypertonicandnot usedforhydration. DIF:Applying/ApplicationREF:812 KEY:Hematologicsystem|anemias|fluidandelectrolyteimbalance|IVfluids|hydration MSC:IntegratedProcess:NursingProcess:Analysis NOT:ClientNeedsCategory:PhysiologicalIntegrity:PharmacologicalandParenteralTherapies 4.Aclientpresentstotheemergencydepartmentinsicklecellcrisis.Whatinterventionbythenursetakes priority?

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a.Administeroxygen. b.Applyanoximetryprobe. c.Givepainmedication. d.StartanIVline. ANS:A Allactionsareappropriate,butrememberingtheABCs,oxygenwouldcomefirst.Themainproblemina sicklecellcrisisistissueandorganhypoxia,soprovidingoxygenhelpshalttheprocess. DIF:Applying/ApplicationREF:812 KEY:Hematologicsystem|anemias|oxygen|oxygentherapy MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 5.Aclienthasaserumferritinlevelof8ng/mLandmicrocyticredbloodcells.Whatactionbythenurseis best? a.Encouragehigh-proteinfoods. b.PerformaHemocculttestontheclientsstools. c.Offerfrequentoralcare. d.Preparetoadministercobalamin(vitaminB12). ANS:B Thisclienthaslaboratoryfindingsindicativeofirondeficiencyanemia.Themostcommoncauseofthis disorderisbloodloss,oftenfromtheGItract.ThenurseshouldperformaHemocculttestontheclientsstools. High-proteinfoodsmayhelpthecondition,butdietaryinterventionstaketimetowork.Thatstilldoesnot determinethecause.Frequentoralcareisnotrelated.Cobalamininjectionsareforperniciousanemia. DIF:Applying/ApplicationREF:814 KEY:Hematologicsystem|anemias|laboratoryvalues MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:PhysiologicalIntegrity:ReductionofRiskPotential 6.AclienthasCrohnsdisease.Whattypeofanemiaisthisclientmostatriskfordeveloping? a.Folicaciddeficiency b.Fanconisanemia c.Hemolyticanemia d.VitaminB12anemia ANS:A MalabsorptionsyndromessuchasCrohnsdiseaseleaveaclientpronetofolicaciddeficiency.Fanconis anemia,hemolyticanemia,andvitaminB12anemiaarenotrelatedtoCrohnsdisease. DIF:Remembering/KnowledgeREF:814 KEY:Hematologicsystem|anemias MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation 7.Anurseinahematologyclinicisworkingwithfourclientswhohavepolycythemiavera.Whichclient shouldthenurseseefirst? a.Clientwithabloodpressureof180/98mmHg b.Clientwhoreportsshortnessofbreath c.Clientwhoreportscalftendernessandswelling d.Clientwithaswollenandpainfulleftgreattoe ANS:B Clientswithpolycythemiaveraoftenhaveclottingabnormalitiesduetothehyperviscousbloodwithsluggish flow.Theclientreportingshortnessofbreathmayhaveapulmonaryembolismandshouldbeseenfirst.The clientwithaswollencalfmayhaveadeepveinthrombosisandshouldbeseennext.Highbloodpressureand goutsymptomsarecommonfindingswiththisdisorder.

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DIF:Applying/ApplicationREF:815 KEY:Polycythemiavera|nursingassessment|respiratorysystem|hematologicsystem|pulmonaryembolism MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 8.Anursingstudentiscaringforaclientwithleukemia.Thestudentaskswhytheclientisstillatriskfor infectionwhentheclientswhitebloodcellcount(WBC)ishigh.Whatresponsebytheregisterednurseisbest? a.IftheWBCsarehigh,therealreadyisaninfectionpresent. b.TheclientisinablastcrisisandhastoomanyWBCs. c.Theremustbeamistake;theWBCsshouldbeverylow. d.ThoseWBCsareabnormalanddontprovideprotection. ANS:D Inleukemia,theWBCsareabnormalanddonotprovideprotectiontotheclientagainstinfection.Theother statementsarenotaccurate. DIF:Understanding/ComprehensionREF:818 KEY:Leukemia|infection|laboratoryvalues MSC:IntegratedProcess:Teaching/Learning NOT:ClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation 9.Thefamilyofaneutropenicclientreportstheclientisnotactingright.Whatactionbythenurseisthe priority? a.Asktheclientaboutpain. b.Assesstheclientforinfection. c.Delegatetakingasetofvitalsigns. d.Lookattodayslaboratoryresults. ANS:B Neutropenicclientsoftendonothaveclassicmanifestationsofinfection,butinfectionisthemostcommon causeofdeathinneutropenicclients.Thenurseshouldassessforinfection.Thenurseshouldassessforpain butthisisnotthepriority.Thenurseshouldtaketheclientsvitalsignsinsteadofdelegatingthemsincethe clienthashadachangeinstatus.Laboratoryresultsmaybeinconclusive. DIF:Applying/ApplicationREF:819 KEY:Neutropenia|infection|hematologicsystem|nursingassessment MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 10.Anurseiscaringforaclientwhoisabouttoreceiveabonemarrowtransplant.Tobesthelptheclientcope withthelongrecoveryperiod,whatactionbythenurseisbest? a.Arrangeavisitationscheduleamongfriendsandfamily. b.Explainthatthisprocessisdifficultbutmustbeendured. c.Helptheclientfindthingstohopeforeachdayofrecovery. d.Provideplentyofdiversionaryactivitiesforthistime. ANS:C Providinghopeisanessentialnursingfunctionduringtreatmentforanydiseaseprocess,butespeciallyduring therecoveryperiodafterbonemarrowtransplantation,whichcantakeupto3weeks.Thenursecanhelpthe clientlookaheadtotherecoveryperiodandidentifythingstohopeforduringthistime.Visitorsareimportant toclients,butmayposeaninfectionrisk.Tellingtheclienttherecoveryperiodmustbeendureddoesnot acknowledgehisorherfeelings.Diversionaryactivitiesareimportant,butnotasimportantasinstillinghope. DIF:Applying/ApplicationREF:823 KEY:Psychosocialresponse|caring|hematologicsystem|bonemarrowtransplant MSC:IntegratedProcess:Caring NOT:ClientNeedsCategory:PsychosocialIntegrity 11.Anursingstudentisstrugglingtounderstandtheprocessofgraft-versus-hostdisease.Whatexplanationby

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thenurseinstructorisbest? a.Becauseofimmunosuppression,thedonorcellstakeover. b.Itslikeatransfusionreactionbecausenoperfectmatchesexist. c.Theclientscellsarefightingdonorcellsfordominance. d.Thedonorscellsareactuallyattackingtheclientscells. ANS:D Graftversushostdiseaseisanautoimmune-typeprocessinwhichthedonorcellsrecognizetheclientscellsas foreignandbeginattackingthem.Theotheranswersarenotaccurate. DIF:Understanding/ComprehensionREF:823 KEY:Hematologicsystem|bonemarrowtransplant MSC:IntegratedProcess:Teaching/Learning NOT:ClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation 12.Thenurseiscaringforaclientwithleukemiawhohasthepriorityproblemoffatigue.Whatactionbythe clientbestindicatesthatanimportantgoalforthisproblemhasbeenmet? a.Doingactivitiesofdailyliving(ADLs)usingrestperiods b.Helpingplanadailyactivityschedule c.Requestingasleepingpillatnight d.Tellingvisitorstoleavewhenfatigued ANS:A Fatigueisacommonproblemforclientswithleukemia.ThisclientismanaginghisorherownADLsusing restperiods,whichindicatesanunderstandingoffatigueandhowtocontrolit.Helpingtoplananactivity scheduleisalesserindicator.Requestingasleepingpilldoesnothelpcontrolfatigueduringtheday.Asking visitorstoleavewhentiredisanotherlesserindicator.ManagingADLsusingrestperiodsdemonstratesthe mostcomprehensivemanagementstrategy. DIF:Evaluating/SynthesisREF:818 KEY:Hematologicsystem|leukemia|sleepandrest|activity MSC:IntegratedProcess:NursingProcess:Evaluation NOT:ClientNeedsCategory:PhysiologicalIntegrity:BasicCareandComfort 13.Anurseiscaringforayoungmaleclientwithlymphomawhoistobegintreatment.Whatteachingtopicis apriority? a.Genetictesting b.Infectionprevention c.Spermbanking d.Treatmentoptions ANS:C Allteachingtopicsareimportanttotheclientwithlymphoma,butforayoungmale,spermbankingisof particularconcerniftheclientisgoingtohaveradiationtothelowerabdomenorpelvis. DIF:Understanding/ComprehensionREF:827 KEY:Lymphoma|hematologicsystem|caring|reproductiveproblems MSC:IntegratedProcess:Teaching/Learning NOT:ClientNeedsCategory:HealthPromotionandMaintenance 14.Aclienthasbeenadmittedaftersustainingahumerusfracturethatoccurredwhenpickingupthefamily cat.Whattestresultwouldthenursecorrelatetothiscondition? a.Bence-Jonesproteininurine b.Epstein-Barrvirus:positive c.Hemoglobin:18mg/dL d.Redbloodcellcount:8.2/mm3 ANS:A Thisclienthaspossiblemultiplemyeloma.ApositiveBence-Jonesproteinfindingwouldcorrelatewiththis

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condition.TheEpstein-Barrvirusisaherpesvirusthatcausesinfectiousmononucleosisandsomecancers.A hemoglobinof18mg/dLisslightlyhighforamaleandsomewhathighforafemale;thiscanbecausedby severalconditions,andfurtherinformationwouldbeneededtocorrelatethisvaluewithaspecificmedical condition.Aredbloodcellcountof8.2/mm3isalsohigh,butagain,moreinformationwouldbeneededto correlatethisfindingwithaspecificmedicalcondition. DIF:Applying/ApplicationREF:829 KEY:Hematologicsystem|laboratoryvalues MSC:IntegratedProcess:NursingProcess:Assessment NOT:ClientNeedsCategory:PhysiologicalIntegrity:ReductionofRiskPotential 15.Aclientwithmultiplemyelomademonstratesworseningbonedensityondiagnosticscans.Aboutwhat drugdoesthenurseplantoteachthisclient? a.Bortezomib(Velcade) b.Dexamethasone(Decadron) c.Thalidomide(Thalomid) d.Zoledronicacid(Zometa) ANS:D Alltheoptionsaredrugsusedtotreatmultiplemyeloma,butthedrugusedspecificallyforbonemanifestations iszoledronicacid(Zometa),whichisabisphosphonate.Thisdrugclassinhibitsboneresorptionandisusedto treatosteoporosisaswell. DIF:Applying/ApplicationREF:829 KEY:Hematologicsystem|bisphosphonates|patienteducation MSC:IntegratedProcess:Teaching/Learning NOT:ClientNeedsCategory:PhysiologicalIntegrity:PharmacologicalandParenteralTherapies 16.Aclientwithautoimmuneidiopathicthrombocytopenicpurpura(ITP)hashadasplenectomyandreturned tothesurgicalunit2hoursago.Thenurseassessestheclientandfindstheabdominaldressingsaturatedwith blood.Whatactionismostimportant? a.Preparingtoadministerabloodtransfusion b.Reinforcingthedressinganddocumentingfindings c.Removingthedressingandassessingthesurgicalsite d.Takingasetofvitalsignsandnotifyingthesurgeon ANS:D Whilesomebloodydrainageonanewsurgicaldressingisexpected,asaturateddressingisnot.Thisclientis alreadyathighriskofbleedingduetotheITP.Thenurseshouldassessvitalsignsforshockandnotifythe surgeonimmediately.Theclientmayormaynotneedatransfusion.Reinforcingthedressingisanappropriate action,butthenurseneedstodomorethandocumentafterward.Removingthedressingincreasestheriskof infection;plus,itisnotneededsincethenurseknowswherethebleedingiscomingfrom. DIF:Applying/ApplicationREF:830 KEY:Hematologicsystem|nursingassessment|surgicalprocedures|dressings|postoperativecareMSC: IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:PhysiologicalIntegrity:PhysiologicalAdaptation 17.Aclienthasaplateletcountof9000/mm3.Thenursefindstheclientconfusedandmumbling.Whataction takespriority? a.CallingtheRapidResponseTeam b.Delegatingtakingasetofvitalsigns c.Institutingbleedingprecautions d.Placingtheclientonbedrest ANS:A Withaplateletcountthislow,theclientisathighriskofspontaneousbleeding.Themostdisastrous complicationwouldbeintracranialbleeding.ThenurseneedstocalltheRapidResponseTeamasthisclient hasmanifestationsofasuddenneurologicchange.Thenurseshouldnotdelegatethevitalsignsastheclientis

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nolongerstable.Bleedingprecautionswillnotaddresstheimmediatesituation.Placingtheclientonbedrestor puttingtheclientbackintobedisimportant,butthecriticalactionistocallforimmediatemedicalattention. DIF:Applying/ApplicationREF:830 KEY:Hematologicsystem|laboratoryvalues|criticalrescue|neurologicsystem MSC:IntegratedProcess:CommunicationandDocumentation NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 18.Anurseispreparingtoadministerabloodtransfusion.Whatactionismostimportant? a.Correctlyidentifyingclientusingtwoidentifiers b.Ensuringinformedconsentisobtainedifrequired c.HangingthebloodproductwithRingerslactate d.Stayingwiththeclientfortheentiretransfusion ANS:B Ifthefacilityrequiresinformedconsentfortransfusions,thisactionismostimportantbecauseitprecedesthe otheractionstakenduringthetransfusion.CorrectlyidentifyingtheclientandbloodproductisaNational PatientSafetyGoal,andisthemostimportantactionafterobtaininginformedconsent.Ringerslactateisnot usedtotransfuseblood.Thenursedoesnotneedtostaywiththeclientforthedurationofthetransfusion. DIF:Applying/ApplicationREF:815 KEY:Informedconsent|bloodtransfusions|hematologicsystem MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 19.Anurseispreparingtohangabloodtransfusion.Whichactionismostimportant? a.Documentingthetransfusion b.PlacingtheclientonNPOstatus c.Placingtheclientinisolation d.Puttingonapairofgloves ANS:D Topreventbloodborneillness,thenurseshoulddonapairofglovespriortohangingtheblood.Documentatio isimportantbutnotthepriorityatthispoint.NPOstatusandisolationarenotneeded. DIF:Applying/ApplicationREF:831 KEY:Bloodtransfusion|hematologicsystem|StandardPrecautions|infectioncontrol MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:SafetyandInfectionControl 20.Aclientreceivingabloodtransfusiondevelopsanxietyandlowbackpain.Afterstoppingthetransfusion, whatactionbythenurseismostimportant? a.Documentingtheeventsintheclientsmedicalrecord b.Double-checkingtheclientandbloodproductidentification c.Placingtheclientonstrictbedrestuntilthepainsubsides d.Reviewingtheclientsmedicalrecordforknownallergies ANS:B Thisclienthadahemolytictransfusionreaction,mostcommonlycausedbybloodtypeorRhincompatibility. Thenurseshoulddouble-checkallidentifyinginformationforboththeclientandbloodtype.Documentation occursaftertheclientisstable.Bedrestmayormaynotbeneeded.Allergiestomedicationsorenvironmental itemsisnotrelated. DIF:Analyzing/AnalysisREF:833 KEY:Bloodtransfusion|CoreMeasures|transfusionreaction MSC:IntegratedProcess:NursingProcess:Implementation NOT:ClientNeedsCategory:SafeandEffectiveCareEnvironment:ManagementofCare 21.Aclienthasthrombocytopenia.Whatclientstatementindicatestheclientunderstandsself-managementof

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thiscondition? a.Ibrushandusedentalflosseveryday. b.Ichewhardcandyformydrymouth. c.Iusuallyputiceonbumpsorbruises. d.NonslipsocksarebestwhenIwalk. ANS:C Theclientshouldbetaughttoapplyicetoareasofminortrauma.Flossingisnotrecommended.Hardfoods shouldbeavoided.Theclientshouldwearwell-fittingshoeswhenambulating. DIF:Evaluating/SynthesisREF:824 KEY:Hematologicsystem|patientsafety|patienteducation MSC:IntegratedProcess:NursingProcess:Evaluation NOT:ClientNeedsCategory:HealthPromotionandMaintenance 22.Aclienthasasicklecellcrisiswithextremelowerextremitypain.Whatcomfortmeasuredoesthenurse delegatetotheunlicensedassistivepersonnel(UAP)? a.Applyicepackstotheclientslegs. b.Elevatetheclientslegsonpillows. c.Keepthelowerextremitieswarm. d.Placeelasticbandagewrapsontheclientslegs. ANS:C Duringasicklecellcrisis,thetissuedistaltotheocclusionhasdecreasedbloodflowandischemia,leadingto pain.Duetodecreasedbloodflow,theclientslegswillbecoolorcold.TheUAPcanattempttokeepthe clientslegswarm.Iceandelevationwillfurtherdecreaseperfusion.Elasticbandagewrapsarenotindicated andmayconstrictperfusioninthelegs. DIF:Applying/Appli...