Chapter 19: Nursing Assessment: Hematologic Function

The Hematologic System

Anatomic and Physiologic Overview
 Consists of the blood and the sites where blood is produced, including the
bone marrow and the reticuloendothelial system (RES)

 Blood is a specialized organ that exists in a fluid state

 Blood is composed of plasma and various types of cells:

 Approximately 55% of blood volume is plasma, and 45% consists of
various cellular components

Blood

 Three primary cell types:

 Erythrocytes (red blood cells [RBCs])
 Leukocytes (white blood cells [WBCs])
 Thrombocytes (platelets)

 Life of Cells
 RBS’s generally 120 days
 WBC’s live from days to years depending on the type
 Platelets live 7 – 10 days

 Hematopoiesis: formation and production of RBS’s; the process of replenishing

blood cells
 Primary site is the bone marrow
 Within it are primitive cells called stem cells
 Stem cells can begin a process of differentiation into either myeloid
or lymphoid stem cells
 Normal bone marrow produces 175 billion erythrocytes, 70 billion neutrophils
(a mature type WBC), and 175 billion platelets DAILY

 Blood makes up 7% - 10% of the normal body weight and mounts to 5 - - L of

volume
 Bone Marrow
 The site for hematopoiesis or blood formation
 In children: blood formation involves ALL skeletal bones BUT with aging,
marrow cavity is limited to the pelvis, ribs, vertebrae, and sternum.
 Marrow = 4% - 5% of total body weight, consists of cellular components
(red marrow) separated by fat (yellow marrow)
 Adults w/ disease causes marrow destruction, fibrosis, or scarring, the
liver and spleen resume production of blood cells (extramedullary
hematopoiesis)
 Marrow is HIGHLY vascular with stem cells in it (ability to self-replicate)
 Lymphoid stem cells produce T or B lymphocytes, where myeloid stem
cells have three broad cell types:
o Erythrocytes, leukocytes, and platelets
o With exception to lymphocytes, ALL blood cells are derived from
myeloid stem cells
 Erythrocytes (Red Blood Cells)

 Mature erythrocytes consist primarily of hemoglobin, which contains iron and

makes up 95% of the cell mass
 Oxygen readily binds to hemoglobin in the lungs and is carried as
oxyhemoglobin in arterial blood

Erythropoiesis
 Erythroblasts arise from the primitive myeloid stem cells in bone marrow
 Differentiation is stimulated by erythropoietin from the kidneys
 Depends on adequate supplies of folic acid, vitamin B 12, and iron
 Old RBCs are removed from the blood by the reticuloendothelial cells,
particularly in the liver and the spleen

Question
Which of the following situations would most likely prompt an increase in
erythropoietin synthesis?
 A woman is admitted to the hospital with anemia.
 A man with atrial fibrillation has begun taking anticoagulants to prevent a stroke.
 A child fractures his ulna and radius in a playground accident.
 A woman develops an infection in an arterial ulcer.
Rationale: If the kidney detects low levels of oxygen (as would occur in anemia, in which
fewer red cells are available to bind oxygen, or with people living at high altitudes), the
release of erythropoietin is increased. Anticoagulants, infections, and injury without
blood loss do not increase erythropoiesis.

Leukocytes (White Blood Cells)

• Two general categories:
1. Granulocytes:
 Eosinophils
 Basophils
 Neutrophils

2. Agranulocytes:
 Monocytes
 Lymphocytes

Question: Is the following statement true or false?

An individual with an active infection is likely to experience an increase in neutrophil
production.
Rationale: Infection is the condition in which neutrophil production most sharply
increases.

Platelets (Thrombocytes)
 Play an essential role in the control of bleeding
 Circulate freely in the blood in an inactive state
 When vascular injury occurs, platelets collect at the site and are activated,
forming a platelet plug

Plasma and Plasma Proteins

 More than 90% water
 Remainder consists primarily of plasma proteins and clotting factors
(particularly fibrinogen
 Plasma proteins consist primarily of albumin and the globulins

Hemostasis
 Involves primary and secondary phases
 Can be activated by the intrinsic or the extrinsic pathway
 Many factors are involved in the reaction cascade that forms fibrin

Question
An individual’s body is responding to a minor cut. What event will take place during
primary hemostasis?
• The severed blood vessels will constrict.
• Thrombopoietin will be synthesized.
• Platelets will begin to circulate.
• Plasma volume will increase.

Rationale: Primary hemostasis involves the severed vessel constricting and platelets
collecting at the injury site. Thrombopoietin is not synthesized in the immediate
response to an injury, and platelets are in constant circulation. Plasma volume does not
increase in response to bleeding.

Complete Blood Count With Differential

 WBC: 5,000–10,000/µL
 Absolute neutrophil count: >1,800/µL

 Segments: 38%–71% of total WBC

 Bands: 0%–10% of total
 Monocytes: 2%–15% of total
 Basophils: 0%–1% of total
 Eosinophils: 0%–5% of total
  Lymphocytes: 20%–40% of total

Absolute Neutrophil Count (ANC)

• Neutropenia severity is classified using the following guidelines:

Neutropenia severity ANC count

Mild 1000 – 1500/mm3
Moderate 500 – 999/mm3
Severe < 500/mm3

• Patients with severe neutropenia are at significantly increased risk for developing
opportunistic infections and sepsis

Absolute Neutrophil Count (ANC)

Normally, the neutrophil count is greater than 2000/mm 3. The actual (or absolute)
neutrophil count (ANC) is calculated using this formula:
 Total WBC X [%segs + %bands]
 Ex: WBC – 3000/mm3 with 72% neutrophils and 3% bands
 Calculate ANC – 3000 X [0.72 + 0.03] =
3000.75 =
2250/mm3

Complete Blood Count With Differential (cont’d)

• Hemoglobin
 Female: 12–16 g/dL
 Male: 14–18 g/dL

• Hematocrit:
 Female: 37%–47%
 Male: 40%–52%
• Platelets: 150–400,000/mm³

Assessing the Patient With Low Hemoglobin and Hematocrit

 Pallor is the most common sign
 Other findings include fatigue, dyspnea, palpitations, poor activity tolerance,
headaches, tinnitus, anorexia, indigestion, irritability, difficulty sleeping or
concentrating, abnormal menstruation, impotence, loss of libido, and chest
pain

Assessing the Patient With a Low WBC Count

  Assess absolute neutrophil count (ANC)
 Multisystemic assessment is necessary

Patients with neutropenia are often not able to manifest the classic signs of
infection.

Assessing the Patient at Risk for Bleeding

 Signs and symptoms of bleeding disorders vary depending on the type and
severity of the defect
 A careful history and physical examination is useful in determining the source
of the hemostatic defect
 Multisystemic assessment is necessary, with an emphasis on the
integumentary system

Bone Marrow Aspiration and Biopsy

 Provide information to assess how a person’s blood cells are being formed,
and to assess the quantity and quality of each type of cell produced within
the marrow
 Procedure
 Nursing care

Question
A nurse is caring for a patient who is 73 years old with a platelet count of 5,000/mm3
resulting from myelodysplastic syndrome. At 10 p.m., the patient complains of a
headache. What should be the nurse’s immediate action to take?

 Administer aspirin per p.r.n. order.

 Administer acetaminophen per p.r.n. order.
 Notify the health care provider.
 Administer a nonpharmacologic intervention, such as a cool compress.

Rationale: Platelet counts ≤10,000/ mm3 are associated with serious episodes of
spontaneous bleeding, including intracranial hemorrhage; thus complaints of headaches
or change in the level of consciousness necessitates immediate notification of the
health care provider.

Question
Mrs. S. presented to her primary care provider with a complaint of a “cold that just won’t
go away.” She has a CBC drawn, revealing the following: WBC 4.5: segs 5, bands 0,
lymphs 45, eosinophils 5, basophils 5, monocytes 5, blasts 35. What is the patient’s
absolute neutrophil count?
  500
 250
 225
 2,250

Rationale: The formula for determining the absolute neutrophil count (ANC) is the white
blood cell (WBC) count multiplied by the sum of the %neutrophil count (segs) and
%bands. An ANC <500 is severe neutropenia and is associated with high risk for
infection.

Question: What is the priority nursing diagnosis for a client experiencing anemia?
 Risk for injury related to poor blood clotting
 Fatigue related to decreased cellular oxygenation
 Risk of infection related to decreased leukocyte
 Imbalanced nutrition: less than body requirements related to anorexia
Rationale: A low red blood cell (RBC) count decreases oxygen availability to the
tissues, and fatigue, shortness of breath, and weakness may be noted.

Question
A patient with thrombocytopenia due to chemotherapy develops a nose bleed
(epistaxis). What is the nurse’s expected response?

 Apply ice to the anterior surface of the nose and place the patient in a
supine position
 Apply pressure to the nares and position the patient in a high Fowler’s
position, leaning slightly forward
 Squeeze the nares together firmly and position the patient in prone
position with mouth open
 Ask the patient to blow the nose vigorously as the nurse applies firm
pressure to the nares

Rationale: Sitting upright decreases the risk of aspiration of blood and pressure is
applied for a minimum of five minutes. Ice may also be applied to the nares. The
patient’s mouth should be open so that blood can drain rather than be swallowed, which
may cause vomiting.

Question
The nurse recognizes which of the following as the most common hematological
condition associated with aging?
 Thrombocytopenia
 Leukopenia
 Agranulocytosis
 Anemia
Rationale: Anemia is the most common hematologic condition affecting elderly patients;
with each successive decade of life, the incidence of anemia increases. Anemia
frequently results from iron deficiency (in the case of blood loss) or from a nutritional
deficiency, particularly folate or vitamin B12 deficiency or protein–calorie malnutrition; it
may also result from inflammation or chronic disease.

What is the major function of WBCs (Leukocytes)? Fighting infection

What is the function of RBCs (Erythrocytes)? Carries hemoglobin to provide oxygen to
tissues
What is the function of Platelets (Thrombocytes)? Fragment of megakaryocytes that provides
basis for coagulation to occur; maintains hemostasis
Why is blood a specialized organ? Exists in a fluid state
What is plasma? The fluid portion of blood
What are the characteristics of plasma? Fluid, colorless and contains various proteins,
clotting factors, electrolytes, waste products, and nutrients
What percentage of the blood volume is plasma? 55%
What percentage of the blood volume consists of various cellular components? 45%
What are the three primary components of blood? RBCs (Erythrocytes)
WBCs (Leukocytes)
Platelets (Thrombocytes)
What is hematopoesis? The formation and production of blood cells
Where is the primary site for hematopoesis? Bone marrow
What is a neutrophil? Mature type of WBC (essential in preventing or limiting bacterial
infection via phagocytosis)
What percentage of the normal body weight does blood make up? 7 to 10% (5 - 6L)
What is a thrombus (p. thrombi) Blood clot
What is fibrinolysis? Clot dissolution
What is the balance between thrombus and fibrinolysis called? Hemostasis
What percentage of the total body weight does bone marrow consist of? 4 - 5%
What do mature erythrocytes primarily consist of? Hemoglobin (which contains Iron)
What makes up 95% of the cell mass of an erythrocytes (RBC)? Hemoglobin
What are the immature forms of erythrocytes called? Reticulocytes
What is oxygen carried as in arterial blood? Oxyhemoglobin
Why is arterial blood a brighter red than venous blood? Oxygen readily binds to hemoglobin
in the lungs and is carried as oxyhemoglobin which contains lesser amounts of oxygen (reduced
hemoglobin)
What are the most common tests used to assess bone marrow function? CBC
Peripheral Blood Smear (PBS)
How is blood used for a CBC and PBS typically obtained? Venipuncture
What does the CBC identify? The total number of blood cells (leukocytes, erythrocytes &
platelets) as well as the hemoglobin, hematocrit & RBC indices
What is hematocrit? Percentage of blood volume consisting of RBCs (erythrocytes)
In what conditions can there be a falsely elevated hematocrit? Fluid volume loss (i.e.
dehydration)
What is the normal range for normal WBC? 5,000 - 10,000/uL
What is the normal range for hemoglobin for males?14 - 18 g/dL
What is the normal range for hemoglobin for females? 12 - 16 g/dL
What is the normal range for hematocrit for males? 40 - 52%
What is the normal range for hematocrit for females? 37 - 47%
What is the normal range for platelet count? 150,000 - 400,000/mm3
What could an increase in WBC indicate? Infection
Do they elderly typically have an increased or decreased WBC count as their baseline?
Decreased
How does the elderly having a decreased WBC count as their baseline indicate in terms of s/s of
infection? s/s of infection are altered (i.e. confusion or changes in mentation) and an increase
in WBC to NORMAL range can indicate a possible infection
What does HnH refer to? Hemoglobin and hematocrit
What is the rationale for the gender difference for HnH? Menstruation, hormones and fluid
retention
What can a decrease in platelets lead to? Bleeding
What is the implications of hemodilution? Decreased concentration of cells and solids in the
blood resulting from increase in fluid; i.e. lower number of cells than average d/t higher volume
of fluid

Blood is diluted with extra volume d/t fluid retention

What is the implication of hemoconcentration? The hematocrit level is greater than normal
in dehydration because the RBC become suspended in a decreased plasma volume
In what population is hemoconcentration common? Elderly (draw blood and all we get are cells
until they receive fluids d/t dehydration)
What are the manifestations when assessing a patient with low HnH (Hemoglobin &
Hematocrit)? Pallor (of the conjunctiva of the eye, nail beds, or oral mucous membranes),
fatigue, DYSPNEA, PALPITATIONS, poor activity intolerance, headaches, tinnitus, anorexia,
indigestion, irritability, difficulty sleeping or concentrating, abnormal menstruations, impotence,
loss of libido, CHEST PAIN
What are the potential reasons for pts with low HnH? Hemorrhage, fracture, anemia,
menstruation, decreased nutrition
What can pts with mild to moderately lowered HnH levels be? Asymptomatic d/t effective
compensatory mechanisms
What is the most common and obvious sign of anemia? Pallor
What are the potential reasons for a decreased WBC count? Compromised immune system (i.e.
cancer, HIV, leukemia) (increased risk for infection)
What must the nurse assess with a low WBC count? Absolute Neutrophil Count (ANC)
What is the formula to calculate ANC? ANC = WBC x [%segs + %bands]

i.e. 1500 x (72% + 3%) = x / 100%

1500 x (0.72 + 0.3) = 1125
What is necessary for a pt with a low WBC count? Multisystemic assessment
What are Segments? Immature WBCs
What are Bands? Mature WBCs
What does an ANC < 2000 indicate? Neutropenic
Are patients with neutropenia able to manifest the classic signs of infection? No
What are the most common sites of infection in neutropenic patients? Respiratory tract, GI
and GU tracts, and the skin
What are the implications of neutropenic precautions/reverse isolations? No fresh fruits &
veggies
No sick visitors
No flowers
What is necessary for pts at risk for bleeding? Multisystemic assessment
What is the strongest predictor of bleeding risk? Hx of bleeding
What do pts with a platelet count of > 10,000/mm3 at risk for? Serious episodes of
spontaneous bleeding
If spontaneous bleeding occurs internally, where can blood pool? In the back d/t gravity (retro-
peritoneal bleed)
What do pts with a platelet count of 20,000/mm3 or less at risk for? Increased risk for
spontaneous bleeding
Do s/s vary widely for pts at risk for bleeding? Yes
What medications can increase the risk for bleeding? Aspirin
What are the bleeding precautions implicated for pts at risk for bleeding? Frequently document
skin assessments
Avoid aspirin & aspirin-containing mediations (NSAIDs)
Assess for use of herbal meds such as Ginkgo biloba
No IM injections
No indwelling catheters
Do not use rectal route for meds or temperature
Use stool softeners or oral laxatives to prevent constipation
Use smallest needles possible when performing venipuncture
Apply pressure to venipuncture site for 5 minutes or until bleeding stops
Use only soft-bristled toothbrushes
No restrictive clothing
Avoid tourniquets or overinflation of BP cuff
Lubricate lips with water-soluble lubricant Q2H
Avoid suctioning if possible
Discourage vigorous coughing or blowing of nose
Use only electric razor for shaving
Padded side rails prn
Prevent falls by ambulating prn
Avoid contact sports
Avoid sexual intercourse until platelet count > 50,000/mm3
Hematest secretions and excretions for occult blood for internal bleeding
What are petechiae? Tiny round brown-purple spots due to bleeding under the skin, may be in a
small area due to minor trauma or widespread due to blood-clotting disorder
What is leukopenia? Decreased number of circulating leukocytes (WBCs)
What is thrombocytopenia? A decrease in platelet count
What are the most common hematologic conditions affecting the elderly? Leukopenia
Thrombocytopenia
Anemia
What are the age-related changes that affect the hematologic conditions in the gerontologic
population? Decrease in RBCs, Hematocrit & WBCs
How is poor nutrition a cause that can affect the gerontologic population in terms of affecting
hematologic conditions? Document what they ate versus % consumed
Dentition & oral hygiene
Economic status
What state is normal bone marrow in? Semifluid state
How is bone marrow aspirated? Through a special hollow core, large-bore needle
Where is bone marrow typically aspirated & biopsies from in adults? Posterior iliac crest
Can the sternum be used to obtain a bone marrow aspirate? Yes
Can the sternum be used to obtain a bone marrow biopsy? No d/t proximity to vital organs
What is the first step in the procedures of a bone marrow aspiration and biopsy? Obtaining
informed consent (cannot be obtained by the RN, only as witness)
What position is the patient in for a bone marrow aspiration or biopsy? Prone or lateral
decubitus position
Do bones contain any nerve endings?No (pt may feel pressure)
Where can a bone marrow aspiration or biopsy be performed? Bedside Room
Procedure Room
OR
What type of needle is usd for bone marrow aspirations and biopsies? SNARECOIL Bone
Marrow Biopsy Needle
What is the purpose of a bone marrow aspiration and biopsy? Provide information to assess
how a person's blood cells are being formed, and to assess the quantity and quality of each type
of cell produced within the marrow
What types of medications should be avoided after a bone marrow aspiration or biopsy if pt
experiences any soreness (common for 1 to 2 days post-procedure)? Aspirin-containing
analgesics (increased risk for bleeding)
What is the nursing care for pts with a bone marrow aspiration or biopsy? Check site for
redness, swelling or irritation
Reinforce pt education pre- and post-procedure
Provide emotional support during procedure
Assist operator
Assess for pain and anxiety
Review post-procedural care (keep site clean and dry for 24 hours; no submerging in tub for 1-2
days (at least 24 hours)
Risk for bleeding and infection (contact MD)
No contact sports
Inform pt who will contact them after the procedure with info on results
In primary hemostasis, does the severed blood vessel dilate? No
Do erythroblasts arise from the primitive myeloid stem cells in bone marrow? Yes
Is anemia the most common hematologic condition affecting elderly patients? Yes
Do platelet defects tend to cause superficial bleeding? Yes
Blood is composed of ________ and various types of cells Plasma
The bone marrow is the site of _________ Hematopoiesis
_________ play a key role in response to parasitic and allergic disease Eosinophils
__________ is the percentage of blood volume consisting of erythrocytes Hematocrit
Mature __________ are the principal cells of the immune system that produce antibodies
Lymphocytes
A nurse is caring for a patient who is 73 y/o with a platelet count of 5,000/mm3 resulting from
myelodysplastic syndrome. At 2200, the pt complains of a headache. What should be the RN's
immediate action to take? Notify the HCP

NOT administer acetaminophen per prn order ... d/t masking manifestation
NOT administer aspirin per prn order ... d/t increased risk for bleeding
NOT admin non-pharm intervention, such as cool compress
Pt presents to HCP with complaint of a "cold that just wont go away". She has a CBC: WBCs
4500 (4.5), segs 5%, bands 0%, lymphs 45, eosinophils 5, basophils 5, monocytes 5, blasts 35.
What is the pt's ANC?ANC = WBC x (%segs + %bands)

ANC = 4500 x (0.05 + 0) = 225

What is the priority RN Dx for a pt experiencing anemia? Fatigue r/t decreased cellular
oxygenation

NOT risk for injury r/t blood clotting ... PLATELET

NOT risk for infection r/t decreased leukocytes ... WBC
NOT imbalanced nutrition r/t anorexia ... HnH
A pt with thrombocytopenia d/t chemotherapy develops epistaxis. What is the RN's expected
response? Apply pressure to the nares and position the pt in high Fowler's position
The RN recognizes which of the following as the most common hematologic condition
associated with aging? Anemia

Honan Practice Questions

1. The nurse is caring for a patient with a hematologic disorder. The patient asks the nurse
where the body forms blood cells. Where should the nurse tell the patient that blood
cells are formed?
A) In the spleen
B) In the kidneys
C) In the bone marrow
 D) In the liver

2. An elderly adult trips over her dog and receives an injury to her skin that causes minor
blood loss. Primary hemostasis is activated in this patient. What occurs during primary
hemostasis?
A) Severed blood vessels constrict.
B) Thromboplastin is released.
C) Prothrombin is converted to thrombin.
D) Fibrin is lysed.

3. A patient has come to the Ob-Gyn clinic with complaints of a heavy menstrual flow.
The nurse knows that red blood cell production will be increased in the patient's body.
Because of this, the nurse is aware that the patient may need to increase her daily intake
of what?
A) Vitamin C
B) Vitamin D
C) Iron
D) Magnesium

4. A patient with renal failure has decreased erythropoietin production. Upon analysis of
the patient's complete blood count (CBC), the nurse will expect which of the following
CBC results?
A) An increased hemoglobin and hematocrit
B) A decreased hemoglobin and hematocrit
C) A decreased mean corpuscular volume (MCV) and mean corpuscular hemoglobin
(MCH)
D) An increased MCV and MCH

5. A patient has asked the nurse about the clotting cascade, and the nurse explains that
plasminogen is a component necessary in the clotting cascade. Where in the body is
plasminogen present?
A) Myocardial muscle tissue
B) All body fluids
C) Cerebral tissue
 D) Renal cells

6. The nurse is caring for a patient whose bone marrow has been replaced by scar tissue in
much of the areas that produce blood cells for the body. 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

7. The nurse is working with a patient who has a hematological disorder. The nurse is
aware that, in the process of hematopoiesis, stem cells differentiate into either myeloid
or lymphoid stem cells. Into what broad cell types do myeloid stem cells differentiate?
Select all that apply.
A) Leukocytes
B) Mast cells
C) Thrombocytes
D) Platelets
E) Erythrocytes

8. A child has suffered a laceration in a playground accident. When a human body receives
an injury that causes blood loss, several processes are involved in maintaining
hemostasis. When a blood clot is no longer needed, what digests the fibrinogen and
fibrin?
A) Plasminogen
B) Thrombin
C) Prothrombin
D) Plasmin

9. The nurse is providing care for a patient with a diagnosis of cellulitis. What laboratory
value would the nurse assess most closely to gauge the patient's infection?
A) Creatinine levels
B) Hepatic function tests
 C) Electrolyte levels
D) White blood cell (WBC) count

10. A patient with esophageal varices secondary to liver cirrhosis has received a transfusion
of frozen plasma. The nurse is aware of the fact that plasma:
A) Acts solely as a solvent for the cellular components of the blood
B) Accounts for the majority of the blood's volume in the body
C) Plays a regulatory role in the process of erythropoiesis
D) Primarily regulates the pH of blood and other body fluids

11. A patient's most recent blood work reveals an elevated level of reticulocytes. The nurse
recognizes that this assessment finding may be suggestive of:
A) An infectious process
B) A lack of oxygen-carrying capacity
C) Fluid volume deficit
D) Oxygen toxicity

12. A nurse is aware of the central role that erythropoietin plays in the initiation of
erythropoiesis. Which of the following individuals would be likely to require
administration of exogenous erythropoietin?
A) A woman who experienced a postpartum hemorrhage after spontaneous vaginal
delivery
B) A child who experienced severe blood loss during a motor vehicle accident
C) A woman who has been diagnosed with hepatic encephalopathy after a long history
of alcohol abuse
D) A man with a diagnosis of acute renal failure secondary to type 1 diabetes

13. A patient's most recent complete blood count (CBC) reveals that her mean corpuscular
volume (MCV) is well below reference ranges. The nurse should identify what potential
contributing factor for this phenomenon?
A) The woman has an iron deficiency.
B) The woman has been exposed to carbon monoxide at some point in the past.
C) The woman is experiencing nephrotoxicity.
D) The woman's oxygen demands are currently lower than normal.
14. A nurse is reviewing the admission blood work of an adult woman who presented with
complaints of progressive fatigue over the past several weeks. The woman's subsequent
blood work is indicative of iron-deficiency anemia. What assessment question by the
nurse most directly addresses the potential cause of the woman's iron deficiency?
A) “Would you say that you tend to eat a well-balanced diet?”
B) “Have you noticed lately that you are passing less urine or that your urine is quite
dilute?”
C) “Have you seen any blood when you have had a bowel movement in recent
weeks?”
D) “Have you had a bad cold or a case of the flu in the past few weeks?”

15. A 66-year-old man underwent a successful partial gastrectomy for the treatment of
stomach cancer 3 years ago. The man had a scheduled follow-up appointment with his
primary caregiver and had blood work completed. The results of the man's blood work
indicated anemia. The nurse who is contributing to the patient's care should recognize
that this patient's anemia may be attributable to what factor?
A) A recurrence of the man's cancer
B) Paralytic ileus
C) Infection
D) Decreased vitamin B12 absorption

16. A patient's health care provider has ordered blood work that included a white blood cell
(WBC) differential. The results of this blood test reveal a bandemia, in which the
patient's WBC count indicates a higher-than-normal proportion of band cells. What
should the nurse infer from this assessment finding?
A) The patient is currently fighting an infection.
B) The patient is deficient in folic acid and/or iron intake.
C) The patient's kidneys are under physiological duress.
D) The patient should be assessed for leukemia and Hodgkin's disease.

17. A patient with a diagnosis of HIV exhibits a decreased level of T lymphocytes. What
consequence does this state present for this patient?
A) The patient will be incapable of mounting a response to allergens.
B) The patient is particularly susceptible to infection.
 C) The patient has diminished oxygen-carrying capacity.
D) The patient will be unable to maintain hemostasis.

18. A patient with a diagnosis of hepatitis C is being treated in the medical unit of the
hospital and has experienced a downward trend in albumin levels. In light of this
diagnostic finding, what assessments should the nurse prioritize?
A) Assessment of the patient's integumentary system and assessment for skin
breakdown on dependent surfaces
B) Assessment of the patient's fluid balance and assessment for third-spacing and
edema
C) Assessment of the patient's urine output, creatinine levels, and blood urea nitrogen
(BUN) levels
D) Assessment for signs and symptoms of metabolic acidosis and metabolic alkalosis

19. A nurse administered a subcutaneous injection to a patient and noted a small amount of
bleeding from the administration site. After a minute, the bleeding ceased, a process that
the nurse attributed to hemostasis. Which of the following physiological phenomena
occurred during secondary hemostasis?
A) The patient's blood vessels surrounding the injection site constricted.
B) Platelets aggregated at the site where the bleeding occurred.
C) The patient's plasma fibrinolytic system was activated.
D) The patient's clotting cascade resulted in the formation of fibrin.

20. An 82-year-old resident of a long-term care facility has had a scheduled appointment
with his primary care provider and had blood work drawn thereafter. The results of the
resident's blood work are suggestive of anemia. How should the nurse best interpret this
laboratory finding?
A) Mild to moderate anemia is considered a normal, age-related change.
B) The resident's anemia is likely the result of psychological stressors.
C) The specific etiology of the resident's anemia should be investigated.
D) The resident would benefit from a high-iron diet and folic acid supplements.
21. An older adult with a history of decreased self-care has been admitted to the geriatric
medical unit after being found in state of dehydration and malnutrition by paramedics.
The admission assessment of the patient included a complete blood count, which
revealed several hematological abnormalities, including a hematocrit of 61%. The nurse
should consequently assess the patient for signs and symptoms of:
A) Gastrointestinal bleeding or other internal hemorrhage
B) Spontaneous clotting and thromboembolism
C) Confusion and decreased level of consciousness
D) Activity intolerance

22. A 44-year-old man with a longstanding diagnosis of AIDS has been admitted to the
hospital with an absolute neutrophil count (ANC) of 385/mm3. When planning the
patient's care, what action should the nurse prioritize?
A) Placing the patient on protective isolation precautions
B) Obtaining the patient's blood type and cross-match in anticipation of transfusion
C) Providing the patient with supplementary oxygen by simple face mask
D) Padding hard surfaces on the patient's bed to reduce the risk of injury

23. While performing a morning assessment of an elderly patient on a subacute medical

unit, the nurse notes petechiae on a patient's lower extremities. When checking this
patient's most recent blood work, the nurse should pay particular attention to the
patient's level of:
A) Platelets
B) Neutrophils
C) Iron
D) Albumin

24. A patient with a recent history of hematologic abnormalities has been scheduled for a
bone marrow biopsy. The patient has expressed to the nurse, “That sounds like an
incredibly painful experience.” How should the nurse best respond to this patient's
concern?
A) “Actually, you won't feel anything other than the initial shot where the doctor
injects anesthetic.”
B) “A bone marrow biopsy can be a painful experience, but know that it is only
ordered when absolutely necessary.”
C) “There is some pressure and pain when the doctor removes the marrow, but this
should only be short-lasting.”
 D) “The doctor will inject some anesthetic into your bone a few hours ahead of time
reduce the pain associated with the procedure.”

25. The nurse is providing patient education in anticipation of the patient's scheduled boned
marrow aspiration and biopsy. When teaching the patient about care after the procedure,
the nurse should encourage the patient to do which of the following?
A) Take aspirin to alleviate pain.
B) Remain on bed rest for 24 to 36 hours after the procedure.
C) Avoid bathing until the site heals.
D) Avoid the use of oral analgesics.
Answer Key

1. C
2. A
3. C
4. B
5. B
6. D
7. A, D, E
8. D
9. D
10. B
11. B
12. D
13. A
14. C
15. D
16. A
17. B
18. B
19. D
20. C
21. B
22. A
23. A
24. C
25. C
 Chapter 20 : Nursing Management: Patients With Hematologic Disorders

Anemia
 A decrease in the number of red blood cells (RBCs)
 Usually classified by morphology (shape of the RBCs):

 Normocytic (normal or average size), macrocytic (larger than normal), or

microcytic (smaller than normal)
 Changes in the color of the RBC are described as normochromic (normal
in color), hyperchromic (darker cellular contents), or hypochromic (pale)

 Hypo proliferative anemias: The marrow cannot produce adequate numbers

of erythrocytes
 Hemolytic anemias involve premature destruction of erythrocytes

Clinical Manifestations and Assessment

 Multisystemic manifestations
– See Box 20-1 in the text
 Medical management of anemia focuses on resolving the underlying cause

Nursing Management of Anemia

 General complications of severe anemia include heart failure, paresthesias,
and confusion
 Nursing care focuses on:
 Managing fatigue
 Promoting nutrition
 Maintaining perfusion

Types of Anemia
 Iron deficiency anemia
  Anemia in renal disease
 Anemia of chronic disease
 Aplastic anemia
 Megaloblastic anemias:
 Caused by deficiencies of either vitamin B12 or folic acid
 Thalassemia
 Immune hemolytic anemia

Question
A patient’s recent fatigue has been attributed to hypo proliferative anemia. You are
aware that this health problem is a result of:
 Inadequate RBC production
 Active loss of RBCs
 Damage to the circulating RBCs
 Distortions in the shape of RBCs

Rationale: Hypo proliferative anemia is usually a result of inadequate numbers of RBCs

being produced by the bone marrow. It is not a result of changes in morphology,
premature destruction, or blood loss.

Question: Is the following statement true or false?

Patient with renal disease are susceptible to anemia because of a deficiency of

erythropoietin.

Rationale: Renal disease causes a deficiency in erythropoietin production, which results

in inadequate RBC production.

Polycythemia
- Means “too many cells in the blood” (ex: erythrocytes)

 Polycythemia vera (PV): A myeloproliferative disorder in which the myeloid stem

cells have escaped normal control mechanisms
 Secondary polycythemia: Caused by excessive production of erythropoietin

Leukemia
 Neoplastic proliferation of one particular hematopoietic cell type (granulocytes,
monocytes, lymphocytes, or infrequently erythrocytes or megakaryocytes)
 The common feature of the leukemias is an unregulated proliferation of
leukocytes in the bone marrow
 Classified according to the stem cell line involved, either lymphoid (relating to
lymphatic tissue) or myeloid (relating to bone marrow)
  Also classified as either acute or chronic

Acute Myeloid Leukemia (AML)

 Results from a defect in the hematopoietic stem cell that differentiates into all
myeloid cells
 Most signs and symptoms of AML result from insufficient production of normal
blood cells.
 Complications include bleeding and infection
 Treatment focuses on aggressive administration of chemotherapy (results in
neutropenia)
 Priority nursing interventions for the patient with AML include infection
prevention, bleeding prevention, promoting comfort, and patient education

Chronic Myeloid Leukemia (CML)

 Arises from a mutation in the myeloid stem cell
 Manifestations vary based on the phase of the disease (chronic versus acute
phase)
 Therapy depends on the stage of disease

Question
When providing care for a patient who has a diagnosis of AML, the nurse should
prioritize which of the following actions?
 Early ambulation
 Education about deep breathing and coughing
 Vigilant hand washing
 Integumentary assessment

Rationale: Patients with AML have a high risk of infection; this risk underlies an
increased need to maintain infection control measures. This supersedes the patient’s
need for early activity, deep breathing, or frequent skin assessment.

Acute Lymphoid Leukemia (ALL)

 Results from an uncontrolled proliferation of immature cells (lymphoblasts)
derived from the lymphoid stem cell
 Normal hematopoiesis is inhibited, resulting in reduced numbers of leukocytes,
erythrocytes, and platelets
 Induction therapy is indicated
 Infections, especially viral infections, are common
 Nursing priorities include the prevention of infection and bleeding, and
management of symptoms such as nausea and pain
Chronic Lymphocytic Leukemia (CLL)
 Typically derived from a malignant clone of B lymphocytes
 Treatment depends highly on the trajectory of the disease

Lymphomas
 Neoplasms of lymphoid tissue, usually derived from B lymphocytes
 Hodgkin’s lymphoma
 Non-Hodgkin’s lymphomas (NHLs)

Multiple Myeloma
 A malignant disease of the most mature form of B lymphocyte, the plasma cell:
 Results in production of high levels of ineffective immunoglobulins
 Most common presenting symptom is bone pain
 No cure, but treatment focuses on corticosteroids and chemotherapy
 Thorough nursing care is essential

Bleeding Disorders
 All result from a disruption in the normal process of hemostasis
 Signs, symptoms, and treatment vary depending on the type of defect

Primary Thrombocythemia
 A marked increase in platelet production, with the platelet count consistently
greater than 600,000/mm3
 Thrombosis is common
 Because these platelets can be dysfunctional, minor or major hemorrhage can
also occur
 Nursing care prioritizes the risks of hemorrhage and thrombosis
 A reactive increase in platelets results in secondary thrombocythemia

Thrombocytopenia
 Low platelet level
 Numerous causes including malignancy, infection, medications, and
disseminated intravascular coagulation
 Management focuses on correction or treatment of the underlying cause

Question
When assessing a patient who has a diagnosis of thrombocytopenia, the nurse should
understand that the patient may present with what sign or symptom of the disease?
  Petechiae
 Cherry angiomas
 Alopecia
 Pruritus

Rationale: Petechiae are pinpoint red or purple hemorrhagic spots on the skin that can
result from low platelet levels. Alopecia (hair loss), pruritus (itching), and cherry
angiomas (benign red spots on the skin surface) are not associated with
thrombocytopenia.

Immune Thrombocytopenic Purpura (ITP)

 The platelet count is decreased by a combination of autoantibody mediated
platelet destruction and impaired platelet production secondary to autoantibody
effects on the megakaryocyte

 Signs include bruising, heavy menses, and petechiae on the extremities or trunk

 Treated with immunosuppressives and IVIG

Von Willebrand’s Disease

 The most common inherited bleeding disorder
 Goal of treatment is to replace the deficient protein and prevent bleeding

Disseminated Intravascular Coagulation (DIC)

 Not a disease but a sign of an underlying condition
 Normal hemostatic mechanisms are altered so that a massive amount of tiny
clots forms in the microcirculation
 Treatment focuses on the underlying cause
 Nursing care prioritizes monitoring and management potential complications

Question: Is the following statement true or false?

When providing care for a patient who has DIC, the nurse should pay particular
attention to the patient’s levels of RBCs, hematocrit, and hemoglobin when reviewing
laboratory results.

Rationale: Priority lab results for the patient with DIC are those related to coagulation,
such as PT, aPTT and D-dimer.
Therapies for Blood Disorders
 Splenectomy
 Therapeutic apheresis: Blood is taken from the patient and passed through a
centrifuge to remove a specific component
 Therapeutic phlebotomy: Removal of a certain amount of blood under controlled
conditions

Blood Component Therapy

 Packed red blood cells (PRBC)
 Factor VIII concentrate
 Intravenous immunoglobulin (IVIG)

Blood Donation
 Directed donation
 Standard donation
 Autologous donation

Blood Transfusion
• Nursing care focuses on pretransfusion assessment, correct technique, and
monitoring for complications of transfusion
 Febrile nonhemolytic transfusion reaction (FNHTR)
 Acute hemolytic reaction
 Delayed hemolytic reaction
 Allergic reaction
 Circulatory overload
 Bacterial contamination

Questions
A patient’s 18-year-old son would like to donate blood. The nurse educates him
regarding eligibility requirements for blood donation. Which of the following statements
demonstrates that he does not understand the education provided?

 “I am so glad that I am old enough to donate.”

 “Because I just got a tattoo a week ago, I am unable to donate.”
 “Because I live with a friend with HIV, I cannot donate.”
 “Because my girlfriend has hepatitis, and we are sexually active, I cannot
donate.”

Rationale: Living with a friend who has HIV is not a contraindication to blood product
donation. Living in close contact or having sexual contact with someone with hepatitis is
a contraindication to donation.
 Questions
The nurse is explaining the potential signs and symptoms of a transfusion reaction to a
patient who is receiving his first blood transfusion. The nurse explains that she will do
which of the following to ensure safe blood product administration? Select all that
apply.
 Check ABO compatibility by comparing the blood product label to the
patient’s medical record.
 Use two patient identifiers, such as the patient’s date of birth and name to
verify the blood product.
 Administer the blood product slowly for the first 15 minutes.
 Administer acetaminophen and diphenhydramine, which are standard
premedication’s used in all transfused patients.
There is no data to support widespread use of premedication’s. Premedication’s are
reserved for patients with a history of transfusion reactions or for patients being
transfused with an incompatible blood product (due to multiple antibodies and difficulty
cross-matching).

Questions
Mrs. Jones is being treated for sepsis. On the second day caring for her, she
experiences epistaxis and persistent bleeding from a venipuncture site. The nurse
suspects DIC. Which of the following lab results supports the nurse’s suspicion?

 Increased fibrinogen, decreased PTT, decreased platelets

 Decreased fibrinogen, increased PTT, increased platelets
 Decreased fibrinogen, increased PTT, decreased platelets
 Increased fibrinogen, increased PTT, increased platelets

Rationale: DIC is marked by fibrinogen and platelet consumption (evidenced by a

decreased fibrinogen and a decreased platelet count) and a prolonged PTT.

Questions
The nurse provides patient education related to the management of iron deficiency
anemia. Which of the following statements made by the patient signifies understanding
of the education provided?

 “I should take my iron pills with a glass of orange juice.”

 “I should take my iron pills with breakfast to decrease stomach upset.”
 “Iron pills often cause constipation, so I should decrease my fluid and fiber
intake.”
 “I will only need to take these pills for a few days and then my problem will
be fixed.”
Rationale: Taking iron with vitamin C or vitamin C–rich foods and juices increases iron
absorption; iron should be taken on an empty stomach; iron causes constipation, so
fiber and water intake should be increased; iron replacement therapy takes months to
replace iron stores.

Review Questions
The nurse is caring for a patient diagnosed with ALL receiving initial treatment. The
patient has been complaining of a dry cough. She also has diminished breath sounds
upon auscultation. Which of the following should the nurse monitor as priority with
regards to potential complications in this patient?
 Hemoglobin
 Absolute neutrophil count (ANC)
 Hematocrit
 Urine
• NCLEX-Style Review Questions
Rationale: During the initial treatment of acute leukemia, the ANC often drops below
100/mm3, placing the patient at very high risk for infection. Empiric antibiotics are used
to preemptively treat infection when the patient has a fever of 100.4°F or greater.

1. The nurse is caring for a patient with a diagnosis of hypoproliferative anemia. When
planning this patient's care, the nurse should be aware that this type of anemia is due to
what?
A) Lack of production of red blood cells (RBCs)
B) Loss of RBCs
C) Injury to the RBCs in circulation
D) Abnormality of RBCs

2. A 12-year-old girl on the oncology unit at children's hospital tells the nurse that she has
discovered that there are several different kinds of leukemia. The child asks the nurse to
explain what makes them all “leukemia.” What should the nurse reply?
A) The different leukemias all have unregulated proliferation of white blood cells.
B) The different leukemias all have unregulated proliferation of red blood cells.
C) The different leukemias all have decrease in production of white blood cells.
D) The different leukemias all have decrease in production of red blood cells.
3. The nurse is currently planning the care of a patient with multiple myeloma who is
experiencing bone destruction. When reviewing the patient's most recent blood work,
what value would the nurse pay particular attention to?
A) Hypercalcemia
B) Hyperproteinemia
C) Elevated serum viscosity
D) Elevated red blood cell (RBC) count

4. A patient, newly diagnosed with thrombocytopenia, is admitted to the medical unit.

After the admission assessment the patient asks the nurse to explain the disease. What
should the nurse explain to the patient about this condition?
A) There could be an attack on the platelets by the antibodies
B) There could be decreased production of platelets
C) There could be elevated platelet production.
D) There could be decreased white blood cell production.

5. A critical care nurse is caring for a patient with autoimmune hemolytic anemia. The
patient is not responding to conservative treatments, and her condition is now becoming
life-threatening. The nurse is aware that a treatment option in this case may include
what?
A) Hepatectomy
B) Vitamin K administration
C) Platelet transfusion
D) Splenectomy

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 is experiencing chest tightness. What is the most appropriate initial action
for the nurse to take?
A) Notify the patient's health care provider.
B) Stop the transfusion immediately.
C) Remove the patient's IV access.
D) Assess the patient's chest sounds and vital signs.
 7. A male patient with advanced leukemia is responding poorly to treatment. The nurse
finds the patient tearful and trying to express his feelings, but he is clearly having
difficulty. What would be the nurse's best response?
A) Tell him that she'll leave for now but she'll be back in while.
B) Offer to call pastoral care.
C) Ask if he would like her to sit with him while he collects his thoughts.
D) Tell him that she can understand how he's feeling.

8. The nurse is providing education to a patient with iron deficiency anemia who has been
prescribed iron supplements. What statement should the nurse include in patient
education?
A) “Take the iron with dairy products to enhance your body's absorption of it.”
B) “You should increase your intake of vitamin E while you're taking iron.”
C) “Iron will likely cause your stools to darken in color.”
D) “Limit foods high in fiber due to the risk for diarrhea.”

9. A nurse is caring for a patient with acute myeloid leukemia (AML) who is preparing to
undergo induction therapy. In preparing a plan of care for this patient, the nurse should
assign the highest priority to which nursing diagnoses?
A) Activity intolerance
B) Risk for infection
C) Ineffective coping
D) Risk for spiritual distress

10. A patient with renal failure is experiencing decreased erythropoietin production. Upon
analysis of the patient's complete blood count (CBC), the nurse will expect which of the
following results?
A) An increased hemoglobin and hematocrit
B) A decreased hemoglobin and hematocrit
C) A decreased mean corpuscular volume (MCV) and mean corpuscular hemoglobin
concentration (MCHC)
D) An increased MCV and MCHC
11. A 50-year-old woman recently sought care from her primary care provider and was
diagnosed with hypoproliferative anemia following a diagnostic workup. The nurse at
the clinic has been charged with the responsibility for organizing the woman's care and
is consequently creating a nursing care plan. When planning this woman's care, what
nursing diagnosis should the nurse prioritize?
A) Decreased cardiac output
B) Risk for fatigue
C) Acute pain
D) Risk for hypothermia

12. A patient with megaloblastic anemia is being treated in an inpatient setting and has daily
blood work ordered. This morning's blood work has become available, and the patient's
hemoglobin and hematocrit are continuing to trend downward. The nurse has contacted
the patient's health care provider to determine whether the health care provider wants to
order a transfusion of packed red blood cells (PRBCs). When considering the efficacy of
this treatment the nurse should understand that:
A) A transfusion of PRBCs may have the potential to create fluid volume overload
and pulmonary edema.
B) The patient's body is likely to destroy the transfused red cells soon after they are
transfused.
C) The patient is deficient in oxygen-carrying capacity more than in the absolute
number of RBCs.
D) The patient will require multiple transfusions over several days to achieve an
increase in Hgb and Hct.

13. A 63-year-old woman has been diagnosed with polycythemia vera (PV) after
undergoing a series of diagnostic tests. When the woman's nurse is providing health
education, what subject should the nurse prioritize?
A) Maintenance of long-term vascular access device
B) Nutritional modifications necessary for maintaining a low-iron diet
C) Strategies for managing activity
D) Lifestyle modifications and techniques for preventing thromboembolism
14. An otherwise healthy 33-year-old woman experienced debilitating and persistent fatigue
over a period of several weeks and was subsequently diagnosed with acute myeloid
leukemia (AML). The woman has been admitted to the hospital for treatment. The nurse
who is providing care for this patient should prioritize which of the following
assessments?
A) Assessing the woman for thrombosis and embolism
B) Assessing the woman for signs and symptoms of infection
C) Assessing the woman's heart rate, rhythm, and circulation
D) Assessing the woman for signs and symptoms of fluid volume overload

15. A 20-year-old man has been admitted to the emergency department with a femoral
fracture as a result of a motorcycle accident. When the nurse is taking the patient's
history, he states, “I had leukemia when I was little kid but they managed to cure it.”
The nurse should suspect that this patient likely had what type of leukemia?
A) Acute lymphoid leukemia (ALL)
B) Chronic lymphoid leukemia (CLL)
C) Acute myeloid leukemia (AML)
D) Chronic myeloid leukemia (CML)

16. A 70-year-old man attended a scheduled check-up with his primary care provider,
during which he exhibited lymphadenopathy and splenomegaly. The man's primary care
provider has ordered blood work to assess the man for chronic lymphocytic leukemia
(CLL). The nurse at the clinic would recognize that a diagnosis of CLL would be most
consistent with what laboratory finding?
A) Increased hemoglobin and hematocrit
B) Increased lymphocytes
C) Decreased platelets
D) Decreased leukocytes

17. The nurse has completed a plan of care for a patient who has been hospitalized for the
treatment of acute leukemia. When planning this patient's care, the nurse has specified
that assessments be performed more often than is the unit norm. Frequent, thorough
assessments are indicated in the treatment of patients with acute leukemia because:
A) Changes in condition must be identified early because treatment options do not
normally exist.
B) Patients with leukemia are often unable to accurately describe their symptoms.
 C) Leukemia has characteristics of chronic diseases as well as acute illnesses.
D) Patients with leukemia often experience clinical changes that may be subtle and
nonspecific.

18. A 50-year-old woman was recently diagnosed with non-Hodgkin's lymphoma (NHL)
and has begun a treatment regimen that includes simultaneous radiation therapy and
chemotherapy. The combination of severe symptoms and aggressive therapy has
necessitated admission to the hospital. When providing care for this patient, which of
the following actions should the nurse implement?
A) Encouraging frequent mobilization and independence in activities of daily living
B) Applying standard precautions conscientiously to reduce the patient's risk of
infection
C) Providing meticulous skin care and turning the patient at least once every 2 hours
D) Monitoring the patient's bowel pattern and facilitating a high-fiber diet

19. The nurse is providing palliative care for a 69-year-old patient who has a diagnosis of
multiple myeloma. The patient states that she enjoyed good health for most of her life
and rarely had to visit her family health care provider until she experienced the first
signs and symptoms of her current illness. Which of the following complaints most
likely prompted the patient to initially seek care?
A) Lymphadenopathy
B) Bone pain
C) Recurrent infections
D) Fatigue and activity intolerance

20. A woman's routine complete blood count (CBC) revealed a highly elevated platelet
level, and subsequent diagnostic testing has resulted in a diagnosis of primary
thrombocythemia. The nurse has begun the relevant health education with the patient.
What should the nurse teach this woman about her health problem?
A) “Primary thrombocythemia creates potential problems at both ends of the clotting
spectrum: inappropriate clotting or inappropriate bleeding.”
B) “Your doctor will likely order a series of blood transfusions for you over the next
several months.”
C) “It's very important that you try to adopt a diet that's high in organ meats and leafy
green vegetables.”
D) “Primary thrombocythemia makes you quite vulnerable to hemorrhage, so you'll
need regular injections of some important clotting factors.”
21. A patient with a diagnosis of immune thrombocytopenic purpura (ITP) is currently
receiving IVIG for the treatment of her health condition. The nurse who is
providing this patient's care is aware that ITP is a consequence of:
A) Inappropriate platelet aggregation on the walls of the great vessels
B) Impaired liver function and the sequestering of platelets by hepatocytes
C) Hemolysis of platelets in individuals who lack immunity to the Epstein-Barr virus
D) Platelet destruction and impaired platelet production resulting from an autoimmune
process

22. A 71-year-old woman with a history of rheumatoid arthritis and chronic heart failure has
been admitted to the hospital for the treatment of a suspected upper gastrointestinal
bleed. When performing an assessment of this patient, which of the following questions
most directly addresses a likely cause of the woman's bleeding disorder?
A) “How closely do you tend to monitor your blood pressure when you're at home?”
B) “Has your doctor prescribed a water pill for your heart failure?”
C) “Do you ever take aspirin to treat the pain of your arthritis?”
D) “Did either of your parents or siblings have problems with bleeding?”

23. An elderly patient has been admitted to the emergency department (ED) after
accidentally overdosing on warfarin, and the patient's initial blood work reveals a
dangerously high international normalized ratio (INR). The ED nurse should anticipate
the need to administer:
A) Calcium gluconate
B) Fresh frozen plasma
C) Low-molecular weight heparin
D) Vitamin K

24. A nurse in the intensive care unit is caring for a patient who is being treated for
urosepsis. Over the past several hours, the patient's condition has deteriorated, and the
care team believes that the patient is experiencing disseminated intravascular
coagulation (DIC). What assessment should the nurse prioritize in the immediate care of
this patient?
A) Close observation for signs of internal or external hemorrhage
B) Monitoring the patient for signs of fluid overload due to polycythemia
C) Assessment of the patient's arterial blood gases (ABGs)
 D) Assessing the patient's passive range of motion to gauge thrombus formation

25. The nurse has been monitoring a patient's vital signs closely after initiating a transfusion
of packed red blood cells (PRBCs). The nurse has observed that the patient's
temperature is trending upward, and the patient is complaining of chills. The nurse has
stopped the transfusion and informed the patient's health care provider, who believes
that the patient is experiencing a febrile nonhemolytic transfusion reaction (FNHTR).
What course of action should the nurse anticipate?
A) Administering a bolus of normal saline
B) Monitoring the patient closely and administering antipyretics
C) Initiating apheresis and administering IV antihistamines
D) Performing a stat cross-match and beginning a transfusion of the correct blood type

Answer Key
1. A
2. A
3. A
4. B
5. D
6. B
7. C
8. C
9. B
10. B
11. B
12. A
13. D
14. B
15. A
16. B
17. D
18. B
19. B
20. A
21. D
22. C
23. D
24. A
25. B