Ch 32 Hematologic and pharmacology

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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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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.

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