Unit M-Hematology

Question 1

The nurse is assessing an older client for any potential hematologic health problem. Which assessment finding is the most significant and would be reported to the primary health care provider?a. Poor skin turgor on both forearms

b. Multiple petechiae and large bruises
c. Dry, flaky skin on arms and legs
d. Decreased body hair distribution

Answer 1

ANS: B
The presence of multiple petechiae and large bruises indicate a possible problem with blood clotting. Older adults typically have poor skin turgor and dry, flaky skin due to decreased body fluid as a result of aging. They also lose body hair or have thinning hair as a normal change of aging.

Question 2

A nurse is assessing a dark-skinned client for pallor. What nursing assessment is best to
assess for pallor in this client?
a. Assess the conjunctiva of the eye.

b. Have the patient open the hand widely.
c. Look at the roof of the patient’s mouth.
d. Palpate for areas of mild swelling.

Answer 2

ANS: A
To assess pallor in dark-skinned people, assess the conjunctiva of the eye or the mucous membranes. Looking at the roof of the mouth can reveal jaundice. Opening the hand widely is not related to pallor, nor is palpating for mild swelling.

Question 3

A hospitalized client has a platelet count of 58,000/mm3 (58  109/L). What action by the nurse is most appropriate?

a. Encourage high-protein foods.
b. Institute neutropenic precautions.
c. Limit visitors to healthy adults.
d. Place the client on safety precautions.

Answer 3

ANS:DWith a platelet count between 40,000 and 80,000/mm3 (40 and 80  109/L), clients are at risk of prolonged bleeding even after minor trauma. The nurse would place the client on safety or bleeding precautions as the most appropriate action. High-protein foods, while healthy, are not the priority. Neutropenic precautions are not needed as the patient’s white blood cell count is not low. Limiting visitors would also be more likely related to a low white blood cell count.

Question 4

A client is having a bone marrow aspiration and biopsy. What action by the nurse takes priority?

a. Administer pain medication first.
b. Ensure that valid consent is in the medical record.
c. Have the client shower in the morning.
d. Premedicate the client with sedatives.

Answer 4

ANS: B
A bone marrow aspiration and biopsy is an invasive procedure that requires informed consent. Pain medication and sedation are important components of care for this client but do not take priority. The client may or may not need or be able to shower

Question 5

What is the nurse’s priority when caring for a client who just completed a bone marrow
aspiration and biopsy?
a. Teach the client to avoid activity for 24 to 48 hours to prevent infection.
b. Administer a nonsteroidal anti-inflammatory drug (NSAID) to promote comfort.
c. Check the pressure dressing frequently for signs of excessive or active bleeding.
d. Report the laboratory results to the primary health care provider

Answer 5

ANS: C
The client having a bone marrow aspiration and biopsy has a puncture wound from the large needle used to extract the bone marrow. Therefore, the client is at risk for bleeding. A NSAID should not be given because it can cause bleeding. Avoiding activity helps to prevent bleeding, not infection, and reporting the results of the biopsy is not the responsibility of the nurse

Question 6

A nurse is caring for four clients. After reviewing today’s laboratory results, which client would the nurse assess first?

a. Client with an international normalized ratio of 2.8
b. Client with a platelet count of 128,000/mm3 (128  109/L).
c. Client with a prothrombin time (PT) of 28 seconds
d. Client with a red blood cell count of 5.1 million/mcL (5.1  1012/L)

Answer 6

ANS:C
A normal PT is 11 to 12.5 seconds. This client is at high risk of bleeding with a PT of 28 seconds. The other values are within normal limits.

Question 7

A client is having a bone marrow aspiration and biopsy and is extremely anxious. What action by the nurse is the most appropriate?

a. Assess the client’s fears and coping mechanisms.
b. Reassure the client that this is a common test.
c. Sedate the client prior to the procedure.
d. Tell the client that he or she will be asleep.

Answer 7

ANS: A
Assessing the client’s specific fears and coping mechanisms helps guide the nurse in providing holistic care that best meets the client’s needs. Reassurance will be helpful but is not the best option. Sedation is usually used. The client may or may not be totally asleep during the procedure.

Question 8

A client is having a radioisotopic imaging scan. What action by the nurse is most important?

a. Assess the client for shellfish allergies.
b. Place the client on radiation precautions.
c. Sedate the client before the scan
d. Teach the client about the procedure.

Answer 8

ANS: D
The nurse should ensure that teaching is done and the client understands the procedure. Contrast dye is not used, so shellfish/iodine allergies are not related. The client will not be radioactive and does not need radiation precautions. Sedation is not used in this procedure.

Question 9

While taking a client history, which factor(s) that place the client at risk for a hematologic health problem will the nurse document? (Select all that apply.)

a. Family history of bleeding problems
b. Diet low in iron and protein
c. Excessive alcohol consumption
d. Family history of allergies
e. Diet high in saturated fats
f. Diet high in Vitamin K

Answer 9

ANS:A,C,FA family history of bleeding problems places the client at risk for having a similar problem. Excessive alcohol can damage the liver where prothrombin is produced. A diet high in Vitamin K can cause excessive clotting because it is a major clotting factor.

Question 10

An older client asks the nurse why “people my age” have weaker immune systems than younger people. What responses by the nurse are best? (Select all that apply.)

a. “Bone marrow produces fewer blood cells as you age.”
b. “You may have decreased levels of circulating platelets.”
c. “You have lower levels of plasma proteins in the blood.”
d. “Lymphocytes become more reactive to antigens.”
e. “Spleen function declines after age 60.”

Answer 10

ANS: A,C
The aging adult has bone marrow that produces fewer cells and decreased blood volume with fewer plasma proteins. Platelet numbers remain unchanged, lymphocytes become less reactive, and spleen function stays the same.

Question 11

The nurse is assessing a client experiencing anemia. Which laboratory findings will the nurse expect for this client? (Select all that apply.)

a. Increased hematocrit
b. Decreased red blood cell count
c. Decreased serum iron
d. Decreased hemoglobin
e. Increased platelet count
f. Decreased white blood cell count

Answer 11

ANS: B,C,D
Clients experiencing anemia have a decreased red blood cell count which leads to a decreased hemoglobin and hematocrit. For some clients, serum iron levels are also decreased. Anemia is not a problem involving platelets or white blood cells

Question 12

A nurse works in a gerontology clinic. What age-related change(s) related to the hematologic system will the nurse expect during health assessment? (Select all that apply.)

a. Dentition deteriorates with more cavities.
b. Nail beds may be thickened or discolored.
c. Progressive loss or thinning of hair occurs.
d. Sclerae begin to turn yellow or pale.
e. Skin becomes more oily.

Answer 12

ANS:B,CCommon findings in older adults include thickened or discolored nail beds, dry (not oily) skin, and thinning hair. The nurse adapts to these changes by altering assessment techniques. Having more dental caries and changes in the sclerae are not normal age-related changes

Question 13

A nurse caring for a client with sickle cell disease (SCD) reviews the client’s laboratory test results. Which finding would the nurse report to the primary health care provider?

a. Creatinine: 2.9 mg/dL (256 mcmol/L)
b. Hematocrit: 30%
c. Sodium: 146 mEq/L (146 mmol/L)
d. White blood cell count: 12,000/mm3 (12  109/L)

Answer 13

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 due to chronic inflammation. A sodium level of 146 mEq/L (146 mmol/L), although slightly high, is not concerning.

Question 14

The nurse is assessing a client in sickle cell disease (SCD) crisis. What priority client problem will the nurse expect?

a. Infection
b. Pallor
c. Pain
d. Fatigue

Answer 14

ANS: C
The priority expected client problem for clients experiencing sickle cell disease crisis is pain, often concentrated in the legs, arms, and joints. Clients may also be fatigued and pale but these symptoms are not a priority for care. Infection is not expected but can occur in clients who have SCD crisis

Question 15

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 Ringer’s solution

Answer 15

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 Ringer’s solution are isotonic. D50 is hypertonic and not used for hydration.

Question 16

A client presents to the emergency department in sickle cell disease crisis. What intervention by the nurse takes priority?

a. Administer oxygen.
b. Initiate pulse oximetry.
c. Give pain medication.
d. Start an IV line.

Answer 16

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.

Question 17

A client hospitalized with sickle cell disease crisis frequently asks for opioid pain medications, often shortly after receiving a dose. The nurses on the unit believe that 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 primary health care provider leave a prescription for a placebo.
d. Tell the client that it is too early to have more pain medication.

Answer 17

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 would provide it. The other options are judgmental and do not address the client’s pain. Giving a placebo is unethical

Question 18

The nurse is caring for a client experiencing sickle cell disease crisis. Which priority action would help prevent infection?

a. Administering prophylactic antibiotics
b. Monitoring the client’s temperature
c. Checking the client’s white blood cell count
d. Performing frequent handwashing

Answer 18

ANS: D
Frequent and thorough handwashing is the most important intervention that helps prevent infection. Antibiotics are not usually used to prevent infection. Monitoring the client’s temperature or white blood cell count helps to detect the presence of infection, but prevent it

Question 19

A nurse in a hematology clinic is working with four clients who have polycythemia vera. Which client would the nurse assess 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

Answer 19

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.

Question 20

The nurse is teaching a client who has pernicious anemia about necessary dietary changes. Which statement by the client indicates understanding about those changes?

a. “I’ll increase animal proteins like fish and meat.”
b. “I’ll work on increasing my fats and carbohydrates.”
c. “I’ll avoid eating green leafy vegetables.
d. “I’ll limit my intake of citrus fruits.”

Answer 20

ANS: A
Clients who have pernicious anemia have a Vitamin B12 deficiency and need to consume foods high in Vitamin B12, such as animal and plant proteins, citrus fruits, green leafy vegetables, and dairy products. While carbohydrates and fats can provide sources of energy, they do not supply the necessary nutrient to improve anemia

Question 21

An assistive personnel is caring for a client with leukemia and asks why the client is still at risk for infection when the white blood cell count (WBC) is high. What response by the nurse is correct?

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 don’t provide protection.”

Answer 21

ANS: D
In leukemia, the WBCs are abnormal and do not provide protection to the client against infection. The other statements are not accurate.

Question 22

The family of a neutropenic client reports that 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. Take a set of vital signs.
d. Review today’s laboratory results.

Answer 22

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 would definitely assess for infection. The nurse would assess for pain but this is not the priority.

Question 23

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.

Answer 23

ANS: C
Providing hope is an essential nursing function during treatment for any disease process, but
GRADESLAB.COM
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 that the recovery period must be endured does not acknowledge his or her feelings. Diversionary activities are important, but not as important as instilling hope

Question 24

A client asks about the process of graft-versus-host disease. What explanation by the nurse is correct?

a. “Because of immunosuppression, the donor cells take over.”
b. “It’s like a transfusion reaction because no perfect matches exist.”
c. “The patient’s cells are fighting donor cells for dominance.”
d. “The donor’s cells are actually attacking the patient’s cells.

Answer 24

ANS: D
Graft-versus-host disease is an autoimmune-type process in which the donor cells recognize the client’s cells as foreign and begin attacking them. The other answers are not accurate.

Question 25

The nurse is caring for a patient with leukemia who has severe fatigue. What action by the client best indicates that an important outcome to manage 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

Answer 25

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.

Question 26

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

Answer 26

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.

Question 27

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 (180 mmol/L)
d. Red blood cell count: 8.2 million/mcL (8.2  1012/L)

Answer 27

ANS: A
This client has possible multiple myeloma. A positive Bence-Jones protein finding would correlate with this condition. The Epstein-Barr virus is a herpesvirus that causes infectious mononucleosis and some cancers. A hemoglobin of 18 mg/dL (180 mmol/L) 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 million/mcL (8.2  1012/L) is also high, but again, more information would be needed to correlate this finding with a specific medical condition.

Question 28

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
b. Dexamethasone
c. Thalidomide
d. Zoledronic acid

Answer 28

ANS: D
All the options are drugs used to treat multiple myeloma, but the drug used specifically for bone manifestations is zoledronic acid, which is a bisphosphonate. This drug class inhibits bone resorption and is used to treat osteoporosis as well.

Question 29

A client has a platelet count of 9000/mm3 (9  109/L). The nurse finds the client confused and mumbling. What nursing action takes priority at this time?

a. Call the Rapid Response Team.
b. Take a set of vital signs.
c. Institute bleeding precautions.
d. Place the client on bedrest.

Answer 29

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. Bleeding precautions will not address the immediate situation. Placing the client on bedrest is important, but the critical action is to call for immediate medical attention.

Question 30

A nurse is preparing to administer a blood transfusion. What action is most important?

a. Correctly identify client using two identifiers.
b. Ensure that informed consent is obtained.
c. Hang the blood product with Ringer’s lactate.
d. Stay with the client for the entire transfusion.

Answer 30

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. Ringer’s lactate is not used to transfuse blood. The nurse does not need to stay with the client for the duration of the transfusion.

Question 31

A nurse is preparing to administer a blood transfusion. Which action is most important?

a. Document the transfusion.
b. Place the client on NPO status.
c. Place the client in isolation.
d. Put on a pair of gloves.

Answer 31

ANS: D
To prevent bloodborne illness, the nurse should don a pair of gloves prior to hanging the blood. Documentation is important but not the priority at this point. NPO status and isolation are not needed

Question 32

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. Document the events in the client’s medical record.
b. Double-check the client and blood product identification.
c. Place the client on strict bedrest until the pain subsides.
d. Review the client’s medical record for known allergies.

Answer 32

ANS: B
This client most likely 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 are not related.

Question 33

A client has thrombocytopenia. What statement indicates that the client understands self-management of 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.”

Answer 33

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.

Question 34

A nurse is caring for four clients with leukemia. After hand-off report, which client would the nurse assess first?

a. Client who had two bloody diarrhea stools this morning.
b. Client who has been premedicated for nausea prior to chemotherapy.
c. Client with a respiratory rate change from 18 to 22 breaths/min.
d. Client with an unchanged lesion to the lower right lateral malleolus.

Answer 34

ANS: A
The client who had two bloody diarrhea stools that morning may be hemorrhaging in the gastrointestinal (GI) tract and should be assessed first to monitor for or avoid the client from going into hypovolemic shock. The client with the slight change in respiratory rate may have an infection or worsening anemia and should be seen next. If the client’s respiratory rate was greater than 28 to 30 breaths/min, the client may need the initial assessment. Marked tachypnea is an early sign of a deteriorating client condition. The other two clients are not a priority at this time.

Question 35

Which statement by a client with leukemia indicates a need for further teaching by the nurse?

a. “I will use a soft-bristled toothbrush and avoid flossing.”
b. “I will not take aspirin or any aspirin product.”
c. “I will use an electric shaver instead of my manual one.”
d. “I will take a daily laxative to prevent constipation.

Answer 35

ANS: D
The client experiencing leukemia need to prevent injury to prevent bleeding, including avoiding hard-bristled toothbrushes, floss, aspirin, and straight or manual safety razors. However, although constipation can cause hemorrhoids or rectal bleeding, laxatives can cause fluid and electrolyte imbalances and abdominal cramping. Stool softeners would be a better option to allow the passage of soft stool.

Question 36

The nurse is assessing a client who has probable lymphoma. What is the most common early assessment finding for clients with this disorder?

a. Weight gain
b. Enlarged painless lymph node(s)
c. Fever at night
d. Nausea and vomiting

Answer 36

ANS: B
The first change that is noted for clients with probable lymphoma is one or more enlarged lymph nodes. The other findings are either not common in clients with lymphoma or later findings.

Question 37

A nurse working with clients diagnosed with sickle cell disease (SCD) teaches about self-management to prevent exacerbations and sickle cell crises. What factor(s) should clients be taught to avoid? (Select all that apply.)

a. Dehydration
b. Exercise
c. Extreme stress
d. High altitudes
e. Pregnancy

Answer 37

ANS: A,C,D,E
Several factors cause red blood cells to sickle in SCD, including dehydration, extreme stress, high altitudes, and pregnancy. Strenuous exercise can also cause sickling, but not unless it is very vigorous.

Question 38

Which risk factor(s) places a client at risk for leukemia? (Select all that apply.)

a. Chemical exposureb. Genetically modified foods
c. Ionizing radiation exposure
d. Vaccinations
e. Viral infections

Answer 38

ANS: A,C,E
Chemical and ionizing radiation exposure and viral infections are known risk factors for developing leukemia. Eating genetically modified food and receiving vaccinations are not known risk factors.

Question 39

The nurse is assessing a client with chronic leukemia. Which laboratory test result(s) is (are) expected for this client? (Select all that apply.)

a. Decreased hematocrit
b. Abnormal white blood cell count
c. Low platelet count
d. Decreased hemoglobin
e. Increased albumin

Answer 39

ANS: A,B,C,D
Chronic leukemia affects all types of blood cells causing a decrease is red blood cells (RBCs) and platelets. When the number of RBCs decreases, the client’s hemoglobin and hematocrit also decrease. White blood cell counts are also abnormal depending on disease progression and management.

Question 40

The nurse is caring for a client being treated for Hodgkin lymphoma. For which side effect(s) of treatment will the nurse assess? (Select all that apply.)

a. Severe nausea and vomiting
b. Low platelet count
c. Skin irritation at radiation site
d. Low red blood cell count
e. High white blood cell count

Answer 40

ANS: A,B,C,D
Drug and radiation therapy for Hodgkin lymphoma cause many side and adverse effects, including all of the choices except for a high white blood cell (WBC) count. Instead, most clients experience a low WBC count making them very susceptible to infections

Question 41

The nurse is preparing to administer a blood transfusion. Which action(s) by the nurse is (are) most appropriate? (Select all that apply.)

a. Hang the blood product using normal saline and a filtered tubing set
b. Take a full set of vital signs prior to starting the blood transfusion.
c. Tell the client that someone will remain at the bedside for the first 5 minutes.
d. Use gloves to start the client’s IV if needed and to handle the blood product.
e. Verify the client’s identity, and checking blood compatibility and expiration time.

Answer 41

ANS: A,B,D
Correct actions prior to beginning a blood transfusion include hanging the product with saline and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using gloves. Someone stays with the client for the first 15 to 20 minutes of the transfusion. Two registered nurses must verify the client’s identity and blood compatibility.

Question 42

Which statement(s) about blood transfusion compatibilities is (are) correct? (Select all that apply.)

a. Donor blood type A can donate to recipient blood type AB.
b. Donor blood type B can donate to recipient blood type O.
c. Donor blood type AB can donate to anyone.
d. Donor blood type O can donate to anyone.
e. Donor blood type A can donate to recipient blood type B.

Answer 42

ANS: A,D
Blood type A can be donated to people who have blood types A or AB. Blood type O can be given to anyone. Blood type B can be donated to people who have blood types B or AB. Blood type AB can only go to recipients with blood type AB

Question 43

The nurse is caring for a client receiving a unit of whole blood. Which nursing action(s) is (are) appropriate regarding infusion administration. (Select all that apply.)

a. Use a dedicated filtered blood administration set.
b. Stay with the client for the first 15 to 20 minutes of the infusion.
c. Infuse the blood over a 30-minute period of time.
d. Monitor and document vital signs per agency policy.
e. Use a 21-gauge or smaller catheter to administer the blood.
f. Infuse the transfusion with intravenous normal saline.

Answer 43

ANS: A,B,D,F
Blood administration requires a dedicated and filtered intravenous set and a larger catheter or needle due to the viscosity of the infusion. Normal saline is the only IV fluid that is compatible with blood. Vital signs are frequently monitored and documented while the client is carefully assesses for signs and symptoms of a blood transfusion reaction, usually within the first 15 to 20 minutes. One unit of blood is administered in no less than 60 minutes.

Question 44

A nurse is preparing to administer a packed red blood cell transfusion to an older adult. Understanding age-related changes, what alteration(s) in the usual protocol is (are) necessary for the nurse to implement? (Select all that apply.)

a. Assess vital signs at least every 15 minutes.
b. Avoid giving other IV fluids.
c. Premedicate to prevent transfusion reaction.
d. Transfuse smaller bags of blood.
e. Transfuse each unit over 8 hours.
f. Assess the client for fluid overload.

Answer 44

ANS: A,B,F
The older adult needs vital signs monitored as often as every 15 minutes for the duration of the transfusion because vital sign changes may be the only indication of a transfusion-related problem. To prevent fluid overload, the nurse obtains a prescription to hold other running IV fluids during the transfusion and assesses the client frequently for signs and symptoms of overload. The other options are not correct.

Question 45

Which assessment finding(s) may indicate that a client may be experiencing a blood transfusion reaction? (Select all that apply.)

a. Tachycardia
b. Fever
c. Bronchospasm d. Tachypnea
e. Urticaria
f. Hypotension

Answer 45

ANS: A,B,C,D,E,F

Several types of blood transfusion reactions can occur and cause all of the findings listed.

Question 46

A client has received a bone marrow transplant and is waiting for engraftment. What action(s) by the nurse are most appropriate? (Select all that apply.)

a. Not allowing any visitors until engraftment
b. Limiting the protein in the client’s diet
c. Placing the client in protective precautions
d. Teaching visitors appropriate hand hygiene
e. Telling visitors not to bring live flowers or plants

Answer 46

ANS: C,D,EThe client waiting for engraftment after bone marrow transplant has no white cells to protect him or her against infection. The client is on protective precautions and visitors are taught hand hygiene. No fresh flowers or plants are allowed due to the standing water in the vase or container that may harbor organisms; clients are also told not to work with houseplants in the home. Limiting protein is not a healthy option and will not promote engraftment.

Question 47

A nurse is caring for an older adult receiving multiple packed red blood cell transfusions. Which assessment finding(s) indicate(s) possible transfusion circulatory overload? (Select all that apply.)

a. Acute confusion
b. Dyspnea
c. Depression
d. Hypertension
e. Bradycardia
f. Bounding pulse

Answer 47

ANS: A,B,D,F
Circulatory overload is the result of excessive body fluid which can cause signs and symptoms of heart failure including dyspnea, increased blood pressure, tachycardia (not bradycardia), and a bounding pulse. Dyspnea is caused by hypoxia which in older adults can cause acute confusion. Depression is not a common finding resulting from fluid overload.

Question 48

What is the primary result of anemia?

a. Increased blood viscosity.
b. Depressed hematopoietic system.
c. Presence of abnormal hemoglobin.
d. Decreased oxygen-carrying capacity of blood.

Answer 48

ANS: D
Anemia is a condition in which the number of red blood cells or hemoglobin concentration is reduced below the normal values for age. This results in a decreased oxygen-carrying capacity of blood. Increased blood viscosity is usually a function of too many cells or of dehydration, not of anemia. A depressed hematopoietic system or abnormal hemoglobin can contribute to anemia, but the definition depends on the deceased oxygen-carrying capacity of the blood.

Question 49

Several blood tests are ordered for a preschool child with severe anemia. She is crying and upset because she remembers the venipuncture done at the clinic 2 days ago. The nurse should explain that:
a. venipuncture discomfort is very brief.
b. only one venipuncture will be needed.
c. topical application of local anesthetic can eliminate venipuncture pain.
d. most blood tests on children require only a finger puncture because a small amount
of blood is needed

Answer 49

ANS: C
Preschool children are very concerned about both pain and the loss of blood. When preparing the child for venipuncture, a topical anesthetic will be used to eliminate any pain. This is a very traumatic experience for preschool children. They are concerned about their bodily integrity. A local anesthetic should be used, and a bandage should be applied to maintain bodily integrity. A promise that only one venipuncture will be needed should not be made in case multiple attempts are required. Both finger punctures and venipunctures are traumatic for children. Both require preparation.

Question 50

What is the most appropriate nursing diagnosis for a child diagnosed with moderate anemia?

a. Activity intolerance related to generalized weakness
b. Decreased cardiac output related to abnormal hemoglobin
c. Risk for injury related to depressed sensorium
d. Risk for Injury related to dehydration and abnormal hemoglobin

Answer 50

ANS:AThe basic pathology in anemia is the decreased oxygen-carrying capacity of the blood. The nurse must assess the child’s activity level (response to the physiologic state). The nursing diagnosis would reflect the activity intolerance. In generalized anemia no abnormal hemoglobin may be present. Only at a level of very severe anemia does cardiac output become altered. No decreased sensorium exists until profound anemia occurs. Dehydration and abnormal hemoglobin are not usually part of anemia.

Question 51

Which statement best explains why iron deficiency anemia is common during toddlerhood?

a. Milk is a poor source of iron.
b. Iron cannot be stored during fetal development.
c. Fetal iron stores are depleted by age 1 month.
d. Dietary iron cannot be started until age 12 months.

Answer 51

ANS: A
Children between the ages of 12 and 36 months are at risk for anemia because cow’s milk is a major component of their diet, and it is a poor source of iron. Iron is stored during fetal development, but the amount stored depends on maternal iron stores. Fetal iron stores are usually depleted by age 5 to 6 months. Dietary iron can be introduced by breastfeeding, iron-fortified formula, and cereals during the first 12 months of life.

Question 52

When teaching the mother of a 9-month-old infant about administering liquid iron preparations, the nurse should include that information?
a. They should be given with meals.
b. They should be stopped immediately if nausea and vomiting occur.
c. Adequate dosage will turn the stools a tarry green color.
d. Preparation should be allowed to mix with saliva and bathe the teeth before
swallowing

Answer 52

ANS: C
The nurse should prepare the mother for the anticipated change in the child’s stools. If the iron dose is adequate, the stools will become a tarry green color. The lack of the color change may indicate insufficient iron. The iron should be given in two divided doses between meals, when the presence of free hydrochloric acid is greatest. Iron is absorbed best in an acidic environment. Vomiting and diarrhea may occur with iron administration. If these occur, the iron should be given with meals, and the dosage reduced and gradually increased as the child develops tolerance. Liquid preparations of iron stain the teeth. They should be administered through a straw, and the mouth rinsed after administration

Question 53

Iron dextran is ordered for a young child with severe iron deficiency anemia. What nursing consideration should be considered?

a. Administering with meals
b. Administering between meals
c. Injecting deeply into a large muscle
d. Massaging injection site for 5 minutes after administration of drug

Answer 53

ANS: C
Iron dextran is a parenteral form of iron. When administered intramuscularly, it must be injected into a large muscle using the Z-track method. Iron dextran is for intramuscular or intravenous administration; it is not taken orally. The site should not be massaged to prevent leakage, potential irritation, and staining of the skin. The administration has no relationship to food since it is not being given orally

Question 54

What intervention should the nurse share with parents on how to prevent iron deficiency anemia in a healthy, term, breastfed infant?

a. Iron (ferrous sulfate) drops after age 1 month
b. Iron-fortified commercial formula can be used by ages 4 to 6 months
c. Iron-fortified solid foods are introduced at 3 months
d. Iron-fortified infant cereal can be introduced at approximately 6 months of age

Answer 54

ANS: D
Breast milk supplies inadequate iron for growth and development after age 5 months. Supplementation is necessary at this time. Iron supplementation or the introduction of solid foods in a breastfed baby is not indicated. Introducing iron-fortified infant cereal at 2 months should be done only if the mother is choosing to discontinue breastfeeding.

Question 55

What term is used to identify the condition in which the normal adult hemoglobin is partly or completely replaced by abnormal hemoglobin?

a. Aplastic anemia
b. Sickle cell anemia
c. Thalassemia major
d. Iron deficiency anemia

Answer 55

ANS: B
Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which normal adult hemoglobin is replaced by abnormal hemoglobin. Aplastic anemia is a lack of cellular elements being produced. Hemophilia refers to a group of bleeding disorders in which there is deficiency of one of the factors necessary for coagulation. Iron deficiency anemia affects size and depth of color of hemoglobin and does not involve abnormal hemoglobin

Question 56

Which statement most accurately describes the pathologic changes of sickle cell anemia?

a. Sickle-shaped cells carry excess oxygen
b. Sickle-shaped cells decrease blood viscosity
c. Increased red blood cell destruction occurs
d. Decreased red blood cell destruction occurs

Answer 56

ANS: C
The clinical features of sickle cell anemia are primarily the result of increased red blood cell destruction and obstruction caused by the sickle-shaped red blood cells. Sickled red cells have decreased oxygen-carrying capacity and transform into the sickle shape in conditions of low oxygen tension. When the sickle cells change shape, they increase the viscosity in the area where they are involved in the microcirculation.

Question 57

Which clinical manifestation should the nurse expect when a child diagnosed with sickle cell anemia experiences an acute vaso-occlusive crisis?

a. Circulatory collapse
b. Cardiomegaly, systolic murmurs
c. Hepatomegaly, intrahepatic cholestasis
d. Painful swelling of hands and feet, painful joints

Answer 57

ANS: D
A vaso-occlusive crisis is characterized by severe pain in the area of involvement. If in the extremities, painful swelling of the hands and feet is seen; if in the abdomen, severe pain resembles that of acute surgical abdomen; and if in the head, stroke and visual disturbances occur. Circulatory collapse results from sequestration crises. Cardiomegaly, systolic murmurs, hepatomegaly, and intrahepatic cholestasis result from chronic vaso-occlusive phenomen

Question 58

The parents of a child hospitalized with sickle cell anemia tell the nurse that they are concerned about narcotic analgesics causing addiction. The nurse should provide what explanation in response to the parent’s concern?

a. Narcotics are often ordered but not usually needed.
b. Narcotics rarely cause addiction when they are medically indicated.
c. Narcotics are given as a last resort because of the threat of addiction.
d. Narcotics are used only if other measures such as ice packs are ineffective.

Answer 58

ANS: B
The pain of sickle cell anemia is best treated by a multidisciplinary approach. Mild-to-moderate pain can be controlled by ibuprofen and acetaminophen. When narcotics are indicated, they are titrated to effect and given around the clock. Patient-controlled analgesia reinforces the patient’s role and responsibility in managing the pain and provides flexibility in dealing with pain. Few if any patients who receive opioids for severe pain become behaviorally addicted to the drug. Narcotics are often used because of the severe nature of the pain of vaso-occlusive crisis. Ice is contraindicated because of its vasoconstrictive effects.

Question 59

Which statement correctly describes -thalassemia major (Cooley’s anemia)?

a. All formed elements of the blood are depressed.
b. Inadequate numbers of red blood cells are present.
c. Increased incidence occurs in families of Mediterranean extraction.
d. Increased incidence occurs in persons of West African descent.

Answer 59

ANS: C
Individuals who live near the Mediterranean Sea and their descendants have the highest incidence of thalassemia. An overproduction of red cells occurs. Although numerous, the red cells are relatively unstable. Sickle cell disease is common in blacks of West African descent.

Question 60

Chelation therapy is begun on a child with -thalassemia major with what expected result?

a. Treatment of the disease.
b. Elimination of excess iron.
c. Decreasing the risk of hypoxia.
d. Managing nausea and vomiting.

Answer 60

ANS: B
A complication of the frequent blood transfusions in thalassemia is iron overload. Chelation therapy with deferoxamine (an iron-chelating agent) is given with oral supplements of vitamin C to increase iron excretion. Chelation therapy treats the side effects of disease management. Decreasing the risk of hypoxia and managing nausea and vomiting are not the purposes of chelation therapy.

Question 61

In which condition are all the formed elements of the blood simultaneously depressed?

a. Aplastic anemia
b. Sickle cell anemia
c. Thalassemia major
d. Iron deficiency anemia

Answer 61

ANS: A
Aplastic anemia refers to a bone marrow-failure condition in which the formed elements of the blood are simultaneously depressed. Sickle cell anemia is a hemoglobinopathy in which normal adult hemoglobin is partly or completely replaced by abnormal sickle hemoglobin. Thalassemia major is a group of blood disorders characterized by deficiency in the production rate of specific hemoglobin globin chains. Iron deficiency anemia results in a decreased amount of circulating red cells

Question 62

As related to inherited disorders, which statement is descriptive of most cases of hemophilia?
a. Autosomal dominant disorder causing deficiency in a factor involved in the
blood-clotting reaction
b. X-linked recessive inherited disorder causing deficiency of platelets and prolonged
bleeding
c. X-linked recessive inherited disorder in which a blood-clotting factor is deficient
d. Y-linked recessive inherited disorder in which the red blood cells become moon

Answer 62

ANS: C
The inheritance pattern in 80% of all of the cases of hemophilia is X-linked recessive. The two most common forms of the disorder are factor VIII deficiency (hemophilia A or classic hemophilia), and factor IX deficiency (hemophilia B or Christmas disease). The disorder involves coagulation factors, not platelets. The disorder does not involve red cells or the Y chromosome

Question 63

What name is given to identify an acquired hemorrhagic disorder that is characterized by excessive destruction of platelets?

a. Aplastic anemia
b. Thalassemia major
c. Disseminated intravascular coagulation
d. Immune thrombocytopenia

Answer 63

ANS: D
Immune thrombocytopenia is an acquired hemorrhagic disorder characterized by an excessive
destruction of platelets, discolorations caused by petechiae beneath the skin, and a normal
bone marrow. Aplastic anemia refers to a bone marrow failure condition in which the formed
elements of the blood are simultaneously depressed. Thalassemia major is a group of blood
disorders characterized by deficiency in the production rate of specific hemoglobin globin
chains. Disseminated intravascular coagulation is characterized by diffuse fibrin deposition in
the microvasculature, consumption of coagulation factors, and endogenous generation of
thrombin and plasma.

Question 64

Which condition is caused by a virus that primarily infects a specific subset of T lymphocytes, the CD4+ T-cells?

a. Wiskott-Aldrich syndrome
b. Idiopathic thrombocytopenic purpura (ITP)
c. Acquired immunodeficiency syndrome (AIDS)
d. Severe combined immunodeficiency disease

Answer 64

ANS: C
AIDS is caused by the human immunodeficiency virus, which primarily attacks the CD4+ T-cells. Wiskott-Aldrich syndrome, ITP, and severe combined immunodeficiency disease are not viral illnesses.

Question 65

A young child with human immunodeficiency virus is receiving several antiretroviral drugs. What is the expected outcome of these drug therapies?

a. Cure the disease
b. Delay disease progression
c. Prevent spread of disease
d. Treat Pneumocystis jiroveci pneumonia

Answer 65

ANS: B
Although not a cure, these antiviral drugs can suppress viral replication, preventing further deterioration of the immune system, and delay disease progression. At this time cure is not possible. These drugs do not prevent the spread of the disease. Pneumocystis jiroveci prophylaxis is accomplished with antibiotics.

Question 66

Which immunization should be given with caution to children infected with human immunodeficiency virus?

a. Influenza
b. Varicella
c. Pneumococcus
d. Inactivated poliovirus

Answer 66

ANS: B
The children should be carefully evaluated before giving live viral vaccines such as varicella, measles, mumps, and rubella. The child must be immunocompetent and not have contact with other severely immunocompromised individuals. Influenza, pneumococcus, and inactivated poliovirus are not live vaccines.

Question 67

An 8-year-old girl is receiving a blood transfusion when the nurse notes that she has developed precordial pain, dyspnea, distended neck veins, slight cyanosis, and a dry cough. These manifestations are most suggestive of what associated adverse reaction?

a. Air embolism
b. Allergic reaction
c. Hemolytic reaction
d. Circulatory overload

Answer 67

ANS: D
The signs of circulatory overload include distended neck veins, hypertension, crackles, dry cough, cyanosis, and precordial pain. Signs of air embolism are sudden difficulty breathing, sharp pain in the chest, and apprehension. Allergic reactions are manifested by urticaria, pruritus, flushing, asthmatic wheezing, and laryngeal edema. Hemolytic reactions are characterized by chills, shaking, fever, pain at infusion site, nausea, vomiting, tightness in chest, flank pain, red or black urine, and progressive signs of shock and renal failure.

Question 68

The parents of a child diagnosed with aplastic anemia tell the nurse that a bone marrow transplant (BMT) may be necessary. What should the nurse recognize as important when discussing this with the family?

a. BMT should be done at time of diagnosis.
b. Parents and siblings of child have a 25% chance of being a suitable donor.
c. Finding a suitable donor involves matching antigens from the human leukocyte antigen (HLA) system.
d. If BMT fails, chemotherapy or radiotherapy must be continued.

Answer 68

ANS: C
The most successful BMTs come from suitable HLA-matched donors. The timing of a BMT depends on the disease process involved. It usually follows intensive high-dose chemotherapy and/or radiation therapy. Usually parents only share approximately 50% of the genetic material with their children. A one-in-four chance exists that two siblings will have two identical haplotypes and will be identically matched at the HLA loci. Discussing the continuation of chemotherapy or radiotherapy is not appropriate when planning the BMT. That decision will be made later.

Question 69

What is the priority nursing intervention for a child hospitalized with hemarthrosis resulting from hemophilia?

a. Immobilization and elevation of the affected joint
b. Administration of acetaminophen for pain relief
c. Assessment of the child’s response to hospitalization
d. Assessment of the impact of hospitalization on the family system

Answer 69

ANS: A
Immobilization and elevation of the joint will prevent further injury until bleeding is resolved.
Although acetaminophen may help with pain associated with the treatment of hemarthrosis, it
is not the priority nursing intervention. Assessment of a child’s response to hospitalization is
relevant to all hospitalized children; however, in this situation, psychosocial concerns are
secondary to physiologic concerns. A priority nursing concern for this child is the management of hemarthrosis. Assessing the impact of hospitalization on the family system is relevant to all hospitalized children; however, it is not the priority in this situation.

Question 70

What is the most common mode of transmission of human immunodeficiency virus (HIV) in the pediatric population?

a. Perinatal transmission
b. Sexual abuse
c. Blood transfusions
d. Poor hand washing

Answer 70

ANS: A
Infected women can transmit the virus to their infants across the placenta during pregnancy, at delivery, and through breastfeeding. Cases of HIV infection from sexual abuse have been reported; however, perinatal transmission accounts for most pediatric HIV infections. In the past some children became infected with HIV through blood transfusions; however, improved laboratory screening has significantly reduced the probability of contracting HIV from blood products. Poor hand washing is not an etiology of HIV infection

Question 71

The nurse is planning activity for a 4-year-old child with anemia. Which activity should the nurse plan for this child?

a. Game of “hide and seek” in the children’s outdoor play area
b. Participation in dance activities in the playroom
c. Puppet play in the child’s room
d. A walk down to the hospital lobby

Answer 71

ANS: C
Because the basic pathologic process in anemia is a decrease in oxygen-carrying capacity, an important nursing responsibility is to assess the child’s energy level and minimize excess demands. The child’s level of tolerance for activities of daily living and play is assessed, and adjustments are made to allow as much self-care as possible without undue exertion. Puppet play in the child’s room would not be overly tiring. Hide and seek, dancing, and walking to the lobby would not conserve the anemic child’s energy.

Question 72

A school-age child is admitted in vaso-occlusive sickle cell crisis. The child’s care should include which intervention? (Select all that apply.)

a. Correction of acidosis
b. Adequate hydration
c. Pain management
d. Administration of heparin
e. Replacement of factor VIII

Answer 72

ANS: B, C
The management of crises includes adequate hydration, minimizing energy expenditures, pain management, electrolyte replacement, and blood component therapy if indicated. The acidosis will be corrected as the crisis is treated. Heparin and factor VIII are not indicated in the treatment of vaso-occlusive sickle cell crisis.

Question 73

The nurse is caring for a child with aplastic anemia. Which nursing diagnoses are appropriate? (Select all that apply.)

a. Acute Pain related to vaso-occlusion
b. Risk for Infection related to inadequate secondary defenses or immunosuppression
c. Ineffective Protection related to thrombocytopenia
d. Ineffective Tissue Perfusion related to anemia
e. Ineffective Protection related to abnormal clotting

Answer 73

ANS: B, C, DThese are appropriate nursing diagnosis for the nurse planning care for a child with aplastic anemia. Aplastic anemia is a condition in which the bone marrow ceases production of the cells it normally manufactures, resulting in pancytopenia. The child will have varying degrees of the disease depending on how low the values are for absolute neutrophil count (affecting the body’s response to infection), platelet count (putting the child at risk for bleeding), and absolute reticulocyte count (causing the child to have anemia). Acute Pain related to vaso-occlusion is an appropriate nursing diagnosis for sickle cell anemia for the child in vaso-occlusive crisis, but it is not applicable to a child with aplastic anemia. Ineffective Protection related to abnormal clotting is an appropriate diagnosis for a child with hemophilia.

Question 74

The nurse is planning care for a school-age child admitted to the hospital with hemophilia. Which interventions should the nurse plan to implement for this child? (Select all that apply.)

a. Fingersticks for blood work instead of venipunctures
b. Avoidance of intramuscular (IM) injections
c. Acetaminophen for mild pain control
d. Soft toothbrush for dental hygiene
e. Administration of packed red blood cells

Answer 74

ANS: B, C, D
Nurses should take special precautions when caring for a child with hemophilia to prevent the
use of procedures that may cause bleeding, such as IM injections. The subcutaneous route is
substituted for IM injections whenever possible. Venipunctures for blood samples are usually
preferred for these children. There is usually less bleeding after the venipuncture than after
finger or heel punctures. Neither aspirin nor any aspirin-containing compound should be used.
Acetaminophen is a suitable aspirin substitute, especially for controlling mild pain. A soft toothbrush is recommended for dental hygiene to prevent bleeding from the gums. Packed red blood cells are not administered. The primary therapy for hemophilia is replacement of the missing clotting factor. The products available are factor VIII concentrates.

Question 75

Parents of a school-age child with hemophilia ask the nurse, “Which sports are recommended for children with hemophilia?” Which sports should the nurse recommend? (Select all that apply.)

a. Soccer
b. Swimming c. Basketball d. Golf
e. Bowling

Answer 75

ANS: B, D, EBecause almost all persons with hemophilia are boys, the physical limitations in regard to active sports may be a difficult adjustment, and activity restrictions must be tempered with sensitivity to the child’s emotional and physical needs. Use of protective equipment, such as padding and helmets, is particularly important, and noncontact sports, especially swimming, walking, jogging, tennis, golf, fishing, and bowling, are encouraged. Contact sports such as soccer and basketball are not recommended

Question 76

Which should the nurse teach about prevention of sickle cell crises to parents of a preschool child with sickle cell disease? (Select all that apply.)

a. Limit fluids at bedtime.
b. Notify the health care provider if a fever of 38.5° C (101.3° F) or greater occurs.
c. Give penicillin as prescribed.
d. Use ice packs to decrease the discomfort of vaso-occlusive pain in the legs.
e. Notify the health care provider if your child begins to develop symptoms of cold.

Answer 76

ANS: B, C, E
The most important issues to teach the family of a child with sickle cell anemia are to (1) seek
early intervention for problems, such as a fever of 38.5° C (101.3° F) or greater; (2) give
penicillin as ordered; (3) recognize signs and symptoms of splenic sequestration, as well as
respiratory problems that can lead to hypoxia; and (4) treat the child normally. The nurse
emphasizes the importance of adequate hydration to prevent sickling and to delay the
adhesion-stasis-thrombosis-ischemia cycle. It is not sufficient to advise parents to “force
fluids” or “encourage drinking.” They need specific instructions on how many daily glasses or
bottles of fluid are required. Many foods are also a source of fluid, particularly soups, flavored ice pops, ice cream, sherbet, gelatin, and puddings. Increased fluids combined with impaired kidney function result in the problem of enuresis. Parents who are unaware of this fact frequently use the usual measures to discourage bed-wetting, such as limiting fluids at night. Enuresis is treated as a complication of the disease, such as joint pain or some other symptom, to alleviate parental pressure on the child. Ice should not be used during a vaso-occlusive pain crisis because it vasoconstricts and impairs circulation even more.