Chapter 37: Concepts Of Care For Patients With Hematologic Problems Flashcards
A client returning to clinic 7 weeks after hematopoietic stem cell transplantation for leukemia has a total White blood cell (WBC) count of 5,200/mm3 (5.2 x 109/L) and a neutrophil count of 3000/mm3 (3 x 109/L). What is the nurse’s priority action in view of these values?
A. Notify the health care provider immediately.
B. Assess the client for other symptoms of infection.
C. Document the laboratory report as the only action.
D. Obtain a urine specimen, sputum specimen, and chest X-ray.
Answer: C
Rationale:
The white blood cell count is now within the normal range (5,000 to 10,000/mm3 [5-10 x 109/L]) and the neutrophils represent more than 50% of the count. These values are indicators of successful engraftment. The client is not at any particular risk for infection at this time, nor is this cause to believe that an infection is present. (At any post-transplantation check-up, the client is assessed for infection.)
The family of a client receiving a blood transfusion excitedly report to the nurse that although the the blood bag hanging has the client’s name on it, the bag label says B negative and the client’s blood type is B positive. What is the nurse’s priority action?
A. Alert the blood bank and Rapid Response team to a potential error.
B. Thank the family for being alert and preventing a serious complication.
C. Explain that a person who is Rh positive can receive Rh negative blood.
D. Immediately go and stop the infusion but keep the IV line open with normal saline.
Answer: C
Rationale:
Clients with Rh negative blood types can receive O negative blood because they do not have antibodies against this type of blood. Therefore, the transfusion does not need to be stopped nor does the blood bank need to be notified. The family should be thanked for their observation and helped to understand and encouraged to always report or question something that does not seem right to them. The transfusion can proceed.
A client who is 5 weeks post-transplant from an allogeneic stem cell transplantation for acute lymphocytic leukemia comes to the clinic with a swollen belly and weight gain. Which additional assessment data supports the nurse’s suspicion of possible sinusoidal obstructive syndrome (SOS)? Select all that apply.
A. Jaundiced skin and sclera
B. Platelet count is 28,000/mm3
C. Skin peeling on the hands and feet
D. Mixed chimerism by laboratory finding
E. Slightly below normal body temperature
F. Pain in the upper right abdominal quadrant
Answers: A, F
Rationale:
SOS (formerly called veno-occlusive disease [VOD]) is the blockage of liver blood vessels by Clotting and inflammation (phlebitis) and occurs in about one fifth of patients with HSCT, especially those who received high-dose chemotherapy with alkylating agents. The problem can lead to fatal liver failure and supportive management must occur quickly. Symptoms include jaundice, pain in the right upper quadrant, ascites, weight gain, and liver enlargement. Skin peeling is a symptom of graft vs host disease, not SOS. Mixed chimerism is unrelated to the complication of SOS and indicates some degree of engraftment. The slightly low body temperature is not related to the SOS. The rising platelet count (although not yet to normal values) is a result of engraftment and not SOS.
Which client will the nurse identify as having the greatest risk for development of acute leukemia?
A. A 50 year old being treated with cyclophosphamide for a chronic autoimmune disease.
B. A 20 year old with cystic fibrosis who has been on continuous enzyme replacement therapy since infancy.
C. A 55 year old with diabetes mellitus type 1 who has received insulin injections for 43 years.
D. A 38 year old who has used combination oral contraceptives without a break for 15 years.
CORRECT: A
A 50 year old being treated with cyclophosphamide for a chronic autoimmune disease.
Cyclophosphamide is a cytotoxic agent that damages bone marrow and has been known to induce leukemia.
Which precaution is most important for the nurse to teach a patient with leukemia to prevent an infection by cross-contamination?
A. Reporting any burning on urination immediately
B. Taking antibiotics exactly as prescribed
C. Avoiding crowds and people who are ill
D. Performing mouth care three times daily
CORRECT: C
Avoiding crowds and people who are ill
Infection by cross-contamination occurs when organisms from another person are transmitted to the client. This risk can be reduced for the neutropenic client by avoiding crowds and people who are ill (social distancing). Auto-contamination is the overgrowth of the client’s own normal flora or the translocation of his or her normal flora from its normal location to a different one. Taking antibiotics does not prevent cross-contamination and neither does reporting symptoms of an infection. Performing mouth care frequently can reduce the number of normal flora organisms in the mouth and decrease the risk for developing an infection from auto-contamination but not cross-contamination.
Which observation by the home care nurse when visiting a client who had a stem cell transplant 2 months ago requires immediate action?
A. The spouse is preparing a lettuce salad for lunch.
B. The client’s platelet count remains below 100,000 cells/mm3 (100 × 109/L).
C. A dog is the household pet.
D. A grandchild is visiting after receiving a measles, mumps, and rubella vaccine.
CORRECT: D
A grandchild is visiting after receiving a measles, mumps, and rubella vaccine.
Although the client is discharged to home when the white blood cell count, especially the neutrophil count, is high enough to prevent general infections. However, antibody-mediated immunity takes at least a year to redevelop. During that time, exposure to anyone who has received a recent live-virus vaccination increases the client’s risk for developing the disease caused by the live virus.
Which collaborative problem will the nurse consider to have the highest priority when caring for a client with multiple myeloma?
A. Minimizing the side effects of chemotherapy
B. Helping the client conserve energy
C. Providing pain control
D. Protecting the client from infection
CORRECT: C
Providing pain control
All the listed collaborative problems are important; however, pain control has the highest priority for these clients. This disorder destroys bone and causes intense pain that interferes with mobility and greatly reduces all aspects of the client’s quality of life.
Which instruction is most appropriate for the nurse to teach a client with persistent thrombocytopenia who is being discharged?
A. “Use a soft-bristled toothbrush.”
B. “Avoid large crowds.”
C. “Drink at least 2 L of fluid per day.”
D. “Elevate your lower legs when sitting.”
CORRECT: A
“Use a soft-bristled toothbrush.”
Using a soft-bristled toothbrush reduces the risk for bleeding in the client with thrombocytopenia.
Which action is the first priority for the nurse to take when a client who is receiving a blood transfusion suddenly says, “I don’t feel right!”?
A. Applying oxygen
B. Obtaining vital signs and monitoring for changes
C. Initiating the Rapid Response Team
D. Stopping the transfusion
CORRECT: D
Stopping the transfusion
The nurse’s first action when a client receiving a blood transfusion says, “I don’t feel right,” is to stop the transfusion. The client may be experiencing a transfusion reaction, so the nurse must stop the transfusion immediately. Calling the Rapid Response Team, applying oxygen, or obtaining vital signs is not the first thing that must be done.
Which client will the nurse monitor most closely for development of a febrile transfusion reaction?
A. A 50 year old receiving multiple transfusions for severe hemorrhage
B. A 60 year old receiving an intraoperative autologous transfusion
C. A 40 year old receiving two units of fresh-frozen plasma
D. A 70 year old receiving a rapid transfusion
CORRECT: A
A 50 year old receiving multiple transfusions for severe hemorrhage
Febrile transfusion reactions, not related to infection or transfusion with contaminated blood, occur most often in the client with anti-WBC antibodies, which can develop when receiving multiple transfusions.
Which signs and symptoms in an older client receiving a blood transfusion indicate to the nurse that the client is experiencing transfusion-associated circulatory overload (TACO)?
A. Urticaria, itching, and bronchospasm
B. Hypertension, bounding pulse, and distended neck veins
C. Headache, chest pain, and hemoglobinuria
D. Fever, chills, and tachycardia
CORRECT: B
Hypertension, bounding pulse, and distended neck veins
Older clients are much more at risk for TACO than younger clients. Common symptoms include hypertension, bounding pulse, distended jugular veins, dyspnea, restlessness, and confusion.
Which drugs does the nurse anticipate giving as premedication to client who is to receive a pooled platelet transfusion and has had a previous transfusion reaction?
A. Vitamin K and a diuretic
B. Diphenhydramine and acetaminophen
C. Aspirin and hydroxyurea
D. Hydrocortisone and antihypertensives
CORRECT: B
Diphenhydramine and acetaminophen
A client who has had a transfusion reaction in the past may be given diphenhydramine and acetaminophen before the transfusion to reduce the fever and severe chills (rigors) that often occur during platelet transfusions.
A cousin arrives to visit a client recently diagnosed with leukemia. Which responses will the nurse suggest when the cousin asks, “What should I say to her?” (Select all that apply.)
A. “Just talk about the things you usually talk about with her.”
B. “Remind her to be brave and to not cry.”
C. “Ask how she is feeling.”
D. “Explain what you know about leukemia.”
E. “Ask if you can get or do anything for her.”
F. “Express how sorry you are that this has happened to her.”
CORRECT: A, C, E
“Just talk about the things you usually talk about with her.”
The nurse suggests some comments a family member of a recently diagnosed client with leukemia might say to the client. The first statement may be, “ask her how she is feeling.” This is a broad general opening and would be nonthreatening to the client. Asking if she needs or wants anything a therapeutic communication of offering self and would be considered to be therapeutic and helpful to the client. The family member would talk to her as she normally would when she hasn’t seen her in a long time. There is no need to act differently with the client. If she wants to offer her feelings, keeping a normal atmosphere facilitates that option.
“Ask how she is feeling.”
The nurse suggests some comments a family member of a recently diagnosed client with leukemia might say to the client. The first statement may be, “ask her how she is feeling.” This is a broad general opening and would be nonthreatening to the client. Asking if she needs or wants anything a therapeutic communication of offering self and would be considered to be therapeutic and helpful to the client. The family member would talk to her as she normally would when she hasn’t seen her in a long time. There is no need to act differently with the client. If she wants to offer her feelings, keeping a normal atmosphere facilitates that option.
“Ask if you can get or do anything for her.”
The nurse suggests some comments a family member of a recently diagnosed client with leukemia might say to the client. The first statement may be, “ask her how she is feeling.” This is a broad general opening and would be nonthreatening to the client. Asking if she needs or wants anything a therapeutic communication of offering self and would be considered to be therapeutic and helpful to the client. The family member would talk to her as she normally would when she hasn’t seen her in a long time. There is no need to act differently with the client. If she wants to offer her feelings, keeping a normal atmosphere facilitates that option.
Which action will the nurse perform first when caring for a client with neutropenia who has a suspected infection?
A. Administering prescribed antibiotics
B. Administering IV normal saline for hydration
C. Placing the client on Contact Precautions
D. Drawing blood for cultures
CORRECT: D
Drawing blood for cultures
The priority action for the nurse to take is to draw blood cultures for cultures to identify the infectious agent. This must be done before administering prescribed antibiotics.
What is the nurse’s interpretation of when the blood laboratory values a client who has chronic myelogenous leukemia (CML) shows a high percentage of blast cells and promyelocytes?
A. Infection risk is decreasing.
B. Disease is progressing.
C. Leukemia type is now lymphocytic.
D. Drug therapy is effective.
CORRECT: B
Disease is progressing.
The leukemia is progressing and drug therapy is no longer effective. CML has three phases: The chronic phase is often a slowly progressing (indolent) course with fewer than 10% blast cells at this time. The accelerated phase has progressive symptoms with 10% to 30% blast cells and poor response to therapy. The blast phase indicates transformation to a very aggressive acute leukemia with more than 30% blast cells that commonly spread to other tissues and organs. The leukemia becomes more like acute leukemia than chronic leukemia but does not change from myelogenous to lymphocytic. With so many blast cells that are immature and do not function properly, the client is now at greatly increased risk for infection.