Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking for Collaborative Care, 6th Edition Test Bank Chapter 42: Care of Patients with Hematologic Problems MULTIPLE CHOICE
1. Which clinical manifestation is common to all types types of anemia regardless of cause or pathologic mechanism? A. Jaundiced sclera and roof of the mouth B. Hypertension and peripheral edema C. Tachycardia at basal activity levels D. Increased PaCO2 ANS: C The client with anemia has some degree of tissue hypoxia. A compensatory mechanism to increase tissue oxygenation is to increase cardiac output by increasing heart rate. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity 2. Which laboratory value in a client alerts the nurse to the probability of sickle cell disease? A. Hgb A1: 97% B. Hgb F: 1.5% C. Hgb C: 0% D. Hgb S: 65% ANS: D Normal values for Hgb S should be 0%. Clients with an Hgb S value higher than 43% are considered to have sickle cell disease. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity
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3. The client who has sickle cell trait has a sister with sickle cell disease and a husband with neither the disease nor the trait. She asks he r nurse what her children’s chances are of having sickle cell disease. What is the nurse’s best response? A. “Because you have the trait and your husband does not, only your daughters can have sickle cell disease.” B. “Because you have the trait and your husband does not, none of your children will have the disease, but each child will have a 50% risk for having the trait.” C. “Because your sister actually has sickle cell disease, the risk for your children having sickle sickle cell disease is 50% with each pregnancy.” dau ghters will each have a 50% risk for having h aving the D. “Because you are a woman, your daughters disease and all of your sons will be carriers of the t rait.” ANS: B Sickle cell disease is an autosomal recessive disease. Thus, there are no gender differences or influences in having the disease. Because the disease is recessive, a person needs two mutated gene alleles (homozygous) to have the disease and only one mutated gene allele (heterozygous) to have the trait. This client's husband does not have the disease or the trait and can only contribute a normal hemoglobin gene allele to each child. The client has one abnormal gene allele and has a 50% risk of passing it on to her children with each pregnancy. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Interventi Implementation/Intervention on MSC: Client Needs Category: Physiological Integrity 4. The client in sickle cell crisis has effective pain management. What is now the priority nursing diagnosis? A. Deficient Knowledge related to contraception and pregnancy options B. Deficient Knowledge related to prevention of crisis episodes C. Risk for Injury Injury related to decreased tissue oxygenation D. Risk for Infection Infection related to decreased spleen function ANS: C During sickle cell crisis, when cells are sickled, blood flow is obstructed in the microcirculation and macrocirculation. Depending on which tissue is hypoxic or anoxic, ischemia can lead to tissue injury and cell death. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Safe, Effective Care Environment;
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5. The client has anemia and all the following clinical manifestations. Which manifestation indicates to the nurse that the anemia is a long-standing problem? A. Headache B. Clubbed fingers C. Circumoral pallor D. Orthostatic hypotension ANS: B Clubbing of the fingers requires prolonged hypoxia (many months to years) to develop. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity 6. A nurse administered 8 mg of morphine intravenously 20 minutes ago to the client in sickle cell crisis. Which condition indicates that pain relief has been achieved? A. The client is sleeping. B. The client’s skin is warm and dry. C. The client’s blood pressure is 120/80. D. The client tells the nurse the pain is better. ANS: D The adult client with sickle cell disease experiences pain so chronically that the associated physical changes usually seen with severe pain may be absent. The most reliable indicator of pain relief is the client's subjective response. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Psychosocial Integrity 7. Which problem or condition is most likely to stimulate a crisis in a person who has sickle cell trait? A. Becoming pregnant B. Shoveling snow when the temperature is at 0 degrees C. Having surgery under general anesthesia for colon cancer D. Having a cast placed on the wrist after sustaining a simple fracture ANS: C The person who has sickle cell trait usually has less than 40% of his or her total hemoglobin as Hgb S. Although these cells could still become sickled, hypoxic conditions would have to be severe for this to occur to the level of sickle cell crisis. Such individuals are most vulnerable to crisis during prolonged surgery under anesthesia. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and
Test Bank Maintenance; 8. Which assessment finding alerts the home care nurse to the possibility of infection in the client with sickle cell disease who is recovering from a crisis episode? A. Oral temperature of 37.8 o C (100o F) B. Diminished breath sounds unilaterally C. Firm, nodular texture to the liver on palpation D. Darkened areas of skin on the lower extremities ANS: B The client with sickle cell disease is more susceptible to infections with encapsulated microorganisms such as Streptococcus pneumoniae. Diminished breath sounds, especially if unilateral, indicate possible pneumonia. The other manifestations are expected changes common to adult clients in sickle cell crisis. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Physiological Integrity 9. A. B. C.
Which intervention for the client with sickle cell disease prevents vascular occlusion? Assessing pulse oximetry every 2 hours Administering morphine sulfate every 6 hours Keeping the room temperature at or below 68 o F.
D. Maintaining an oral fluid intake of at least 4500 mL/day ANS: D Venous stasis causes vascular occlusion. Maintaining hydration prevents venous stasis and vascular occlusion. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Safe, Effective Care Environment;
Test Bank 10. Which laboratory test result in a client with sickle cell disease in crisis indicates that the packed red blood transfusion should be discontinued? A. Hct of 32% B. HgbS of 88% C. Serum iron level of 300 mcg/dL D. Total WBC count of 12,000/mm 3 ANS: C Clients with sickle cell disease are anemic but are not iron deficient. Transfusions are prescribed cautiously to prevent iron overload with repeated transfusions. Iron overload damages the heart, liver and endocrine organs. Monitor the client’s serum ferr itin, serum iron (Fe), and total iron-binding capacity (TIBC) during transfusion therapy. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation/Analysis MSC: Client Needs Category: Safe, Effective Care Environment; 11. A. B. C. D.
How does the drug hydroxyurea benefit the client with sickle cell disease? Prevents crises by stimulating the RBCs to synthesize more hemoglobin F Prevents crises by decreasing blood viscosity and reducing vessel obstruction Prevents anemia by stabilizing RBC plasma membranes Prevents anemia by increasing cellular iron storage
ANS: A Hydroxyurea (Droxia) has been successfully used to reduce the number of sickling and pain episodes. Hydroxyurea works by stimulating fetal hemoglobin (Hgb F) production. Hgb F is present during fetal development, but production of Hgb F is turned off before birth. Increasing the level of Hgb F reduces sickling of red blood cells in persons with sickle cell disease. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;
Test Bank 12. Which person should the nurse be most alert for the development of glucose-6-phosphate dehydrogenase (G6PD) deficiency anemia? A. 28-year-old man whose grandfather had the disorder B. 28-year-old woman whose grandfather had the disorder C. 55-year-old man who had a myocardial infarction 5 years ago D. 55-year-old woman who had a partial gastrectomy for stomach cancer last year ANS: A The disorder is inherited as an X-linked recessive trait. Men have only one X chromosome and, if they have the gene mutation, the mutation is expressed as dominant. Women have two X chromosomes and, if one X has the mutation, there are sufficient cells with a healthy X chromosome to avoid manifestations of the disease. The affected grandfather could have passed his affected X chromosome to his daughter (who was then a carrier) who then passed it on to her son. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment/Intervention MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance; 13. Which common agent(s) should the nurse teach the client with glucose-6-phosphate dehydrogenase deficiency anemia to avoid? A. Laxatives B. Aspirin C. Caffeine D. Alcohol ANS: B Cells with reduced amounts of glucose-6-phosphate dehydrogenase are more susceptible to hemolysis on exposure to aspirin and other drugs (phenacetin, sulfonamide antibiotics, quinine derivatives, thiazide diuretics, and vitamin K derivatives). DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Health Promotion and Maintenance
Test Bank 14. Which menu selection made by the client with vitamin B 12 deficiency anemia demonstrates adequate understanding of dietary management for this problem? A. Fried liver and onions, orange juice, spinach salad B. Baked chicken breast, boiled carrots, glass of white wine C. Eggplant Parmesan, cream-style cottage cheese, iced tea D. Whole-grain pasta with cheese, apple sauce, glass of red wine ANS: A Organ meats and leafy green vegetables have the highest content of vitamin B 12. Dairy products are deficient in vitamin B 12. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Health Promotion and Maintenance 15. Which intervention should the nurse teach the client who has IgM-mediated immunohemolytic anemia? A. Use an electric shaver. B. Avoid crowds and sick people. C. Wear socks and gloves in cool weather. D. Do not take aspirin or aspirin-containing products. ANS: C The IgM-mediated type of immunohemolytic anemia fixes complement at 30 o C (– 3.6° F) and is commonly associated with a Raynaud-like response, in which the arteries of the distal extremities constrict profoundly in response to cold temperatures. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Health Promotion and Maintenance 16. Which feature is characteristic of vitamin B 12 deficiency anemia but not A. B. C. D.
characteristic of folic acid deficiency anemia? Weight loss Smooth, beefy-red tongue Macrocytic red blood cells Paresthesias of the hands and feet
ANS: D Vitamin B12 is essential for peripheral nervous system function (folic acid is not). Clients deficient in B12 will manifest nervous system problems, such as paresthesias, in addition to weight loss, fatigue, glossitis, pallor, and jaundice. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment
Test Bank MSC: Client Needs Category: Physiological Integrity 17. The client is prescribed to receive iron dextran by the Z-track method of intramuscular injection. Which technique should the nurse use to adhere to the Z-track method? A. Inject medication only into the dorsal gluteal site. B. Take care to ensure that no air is present in the syringe. C. Select a 22-gauge, 1-inch needle to minimize tissue trauma. D. Massage the site for a minimum of five minutes after the injection. ANS: A The Z-track injection technique is reserved for irritating or staining medications to be administered intramuscularly. The medication must be injected deeply into the tissue of a large muscle to prevent leakage. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Safe, Effective Care Environment; 18. Which of the client's health problems alerts the nurse to the possibility of anemia related to dietary deficiency? A. Mild congestive heart failure B. Ten years of chronic alcoholism C. Poorly controlled diabetes mellitus D. Ten years of antacid therapy for peptic ulcer disease ANS: B Chronic alcohol abuse is strongly associated with malnutrition of many dietary essentials, including iron, folic acid, and vitamin B 12. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity/Health Promotion and Maintenance
Test Bank 19. Which laboratory value indicates that the epoetin alfa (Procrit, Epogen) therapy is effective? A. Platelet count has decreased from 80,000 to 50,000. B. Segmented neutrophils outnumber the band neutrophils. C. Serum potassium level has increased from 3.5 to 4.5 mEq/L D. Red blood cell count has increased from 2.2 million to 3.0 million. ANS: D Epoetin alfa is a growth factor (erythropoietin) that is specific for red blood cell production. An increase in the red blood cell count indicates effectiveness of this therapy. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Physiological Integrity 20. A. B. C. D.
What is the pathologic mechanism involved in aplastic anemia? Decreased intake of iron Increased rate of red blood cell lysis and destruction Decreased bone marrow production of red blood cells Increased (excessive) cellular metabolic oxygen demand
ANS: C The term aplastic indicates arrested development. In the case of aplastic anemia, the bone marrow fails to perform its developmental function of producing blood cells. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A MSC: Client Needs Category: Physiological Integrity 21. What is the priority nursing diagnosis for the client with aplastic anemia who is being treated with a combination of prednisone and cyclophosphamide. A. Risk for Activity Intolerance B. Risk for Infection C. Risk for Injury D. Constipation ANS: B Both prednisone and cyclophosphamide decrease immune function and increase the risk for infection. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;
Test Bank 22. Which teaching intervention should the nurse use for the client with polycythemia vera to prevent injury as a result of the increased bleeding tendency? A. “Use a soft-bristled toothbrush.” B. “Drink at least 3 liters of liquids per day.” C. “Wear gloves and socks outdoors in cool weather.” D. “Exercise slowly and only on the advice of your physician.” ANS: A The other interventions focus on preventing venous stasis, clot formation, and myocardial infarction. Using a soft-bristled toothbrush minimizes trauma to the gums and prevents bleeding. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Health Promotion and Maintenance 23. A. B. C. D.
What is the priority nursing diagnosis for the client with polycythemia vera? Adult Failure to Thrive related to increased energy demands Ineffective Thermoregulation related to excessive heat loss Risk for Injury related to thrombus formation Constipation related to dehydration
ANS: C The blood of the client with polycythemia vera is viscous and slow-moving, increasing the risk for venous stasis and obstruction. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Health Promotion and Maintenance/Safe, Effective Care Environment; 24. Which laboratory finding in a client with polycythemia vera indicates that phlebotomy alone is no longer effective in managing this problem? A. Hematocrit has increased from 55% to 75% B. Hemoglobin A1 c has decreased from 8.0% to 7.0% C. Platelet count has increased from 120,000 to 150,000 D. Segmented neutrophils outnumber the band neutrophils. ANS: A Phlebotomy reduces the percentage of circulating red blood cells. When the client's hematocrit increases during a regimen of phlebotomy, the reduction of red blood cells by phlebotomy is not able to keep pace with the bone marrow production of red blood cells. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Physiological Integrity
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25. Which serum electrolyte value in a client with polycythemia vera should the nurse report to the physician? A. Sodium, 132 mEq/L B. Chloride, 98 mEq/L C. Potassium, 7.2 mEq/L D. Total calcium, 8.7 mg/dL ANS: C The only abnormal electrolyte level is potassium, and the client has hyperkalemia. The major cation in the intracellular fluid is potassium. The extracellular potassium level should range between 3.5 and 5.0 mEq/L. Higher levels of serum potassium can lead to heart block and death. In polycythemia, the client is at risk for hyperkalemia because his or her RBCs are more fragile and break open easily, releasing intracellular potassium. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Safe, Effective Care Environment; 26. Which health problem is most likely to occur in people who have myelodysplastic syndrome? A. Acute leukemia B. Polycythemia vera C. Hodgkin’s lymphoma D. Acute myocardial infarction ANS: A Although not “officially” a type of cancer, MDS has cancer -like features and is considered to be a precursor to cancer. Like cancer, MDS arises from a single population of abnormal cells. About 30% of all clients with MDS do eventually progress to acute leukemia. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A MSC: Client Needs Category: Physiological Integrity
Test Bank 27. Which precaution has the highest priority for instruction of the client going home with thrombocytopenia? A. “Drink at least 3 liters of fluid each day.” B. “Avoid flossing your teeth until platelets return to normal.” C. “Avoid drinking alcoholic beverages until your CBC is no rmal.” D. “Avoid the use of salt substitutes that contain potassium chloride.” ANS: B Decreased platelet counts increase the risk for prolonged bleeding, even with slight injury. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Health Promotion and Maintenance 28. Why is the client with polycythemia vera at an increased risk for a myocardial infarction? A. The rapid synthesis of cells greatly increases metabolism. B. The abnormal hemoglobin in the erythrocytes inadequately oxygenates the myocardium. C. The increased number of erythrocytes increases blood viscosity and the workload of the heart. D. The disease is most prevalent among men in their 60s and 70s who have other conditions that damage the heart. ANS: C Blood viscosity is increased with the hypercellularity, increasing the demand of the pumping action of the heart. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A MSC: Client Needs Category: Physiological Integrity 29. Which clinical manifestation or assessment finding indicates effectiveness of the therapy for the client with polycythemia vera? A. Hematocrit of 65% B. Bilateral darkening of the conjunctiva C. Blood pressure change from 180/150 to 160/90 D. Unplanned weight loss of 6 lb over a month’s time ANS: C Measures that effectively reduce erythrocyte concentration and blood viscosity also reduce blood pressure. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Physiological Integrity
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30. Which precaution should the nurse teach the client who is prescribed to take thalidomide (Thalomid) as part of her treatment plan for multiple myeloma? A. “Avoid high-fiber foods to prevent diarrhea.” B. “Use multiple forms of birth control to prevent birth defects.” C. “Drink plenty of fluids to prevent the development of diabetes mellitus.” D. “Avoid crowds and sick people to prevent contraction of contagious infections.” ANS: B Thalidomide is a potent teratogen and has been known to cause severe birth defects after even one exposure of the drug. Both women and men who are taking this drug are urged to use multiple forms of contraception to prevent exposing a fetus to this drug. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Health Promotion and Maintenance 31. Which question is appropriate when exploring the risk factors for the client newly diagnosed with acute leukemia? A. “How many packs of cigarettes do you smoke per day and for how many years have you smoked?” B. “Have you ever been treated for a sexually transmitted disease?” C. “Have you ever worked around radioactive materials?” D. “How old was your mother when you were born? ” ANS: C A major risk factor for acute leukemia is exposure to high amounts of radiation. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity/Health Promotion and Maintenance
Test Bank 32. The client with leukemia asks his nurse why he is so susceptible to infection when his white blood cell count is so high. What is the nurse’s best response? A. “The number of white blood cells is falsely high because of the severe dehydration that accompanies leukemia.” B. “Even though you have a lot of white blood cells, they are immature and not able to prevent or fight infection.” C. “Your white blood cells have been poisoned by chemotherapy and are now nonfunctional.” D. “It is the platelets, not the white blood cells, that protect you from infection.” ANS: B Leukemia represents an overproduction of very immature white blood cells that have not yet acquired functional status. The excessive bone marrow production of these cells limits production of mature leukocytes that can mount appropriate responses to protect the client from infection. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Health Promotion and Maintenance 33. Which question or statement by the client about to undergo allogeneic bone marrow transplantation indicates a need for further discussion regarding the procedure? A. “Which bone will the surgeon insert the marrow into?” B. “Until the marrow transplant takes, I should have few visitors.” C. “How long will it be before we know if the transplant is successful?” D. “After the bone marrow transplant grows in me, my blood t ype will be the same as the donor's.” ANS: A The transplanted marrow is delivered intravenously; it is not placed into any bone. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Health Promotion and Maintenance/Psychosocial Integrity
Test Bank 34. The client with lymphoma asks his nurse why his disease treatment regimen includes radiation and surgery as well as chemotherapy, when his 16-year-old female cousin only had chemotherapy for leukemia. What is the nu rse’s best response? A. “Radiation is not used as therapy in girls and women so as not to disrupt their childbearing ability.” B. “Lymphomas can form discrete tumors that can be removed by surgery or treated locally with radiation, but leukemic cells are more widespread.” C. “Your disease is probably more widespread and advanced than your cousin's was, requiring additional types of intensive therapy for cure.” D. “Lymphomas can be cured using multiple therapies and leuk emia cannot be cured, only controlled with lifelong inject ions of chemotherapy.” ANS: B Leukemia is cancer of the blood and it is present throughout the body, although the site of malignant cell production is initially the bone marrow. Both surgery and radiation are local or regional treatments and would not be successful in treating systemic disease. Chemotherapy, as systemic treatment, is needed for leukemia. Lymphomas are solid tumors that may be confined to one body area and, therefore, local or regional treatment can be effective. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Psychosocial Integrity/Health Promotion and Maintenance 35. Which client is at greatest risk for development of acute leukemia? A. 50-year-old being treated with cyclophosphamide (Cytoxan) for a chronic autoimmune disease B. 55-year-old with diabetes mellitus type 1 who has received insulin injections for 43 years C. 20-year-old with cystic fibrosis who has been on continuous enzyme replacement therapy since age 3 months D. 38-year-old who has used combination oral contraceptives without a break for 15 years ANS: A Cyclophosphamide is a cytotoxic agent that damages bone marrow and has been known to induce leukemia. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity
Test Bank 36. For which client with leukemia should the nurse be prepared to teach about maintenance therapy? A. The client with acute lymphocytic leukemia who has relapsed B. The client with acute lymphocytic leukemia who is in remission C. The client with acute myelogenous leukemia who has relapsed D. The client with acute myelogenous leukemia who is in remission ANS: B The purpose of maintenance therapy is to maintain an achieved remission. Therefore, it is not appropriate for a client whose leukemia has relapsed. Clinical trials indicate that clients with acute myelogenous leukemia are not helped by maintenance therapy. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Physiological Integrity 37. A. B. C. D.
For which type of leukemia has imatinib mesylate (Gleevec) proven most effective? Acute lymphocytic leukemia that has normal chromosomes Acute myelogenous leukemia that has abnormal chromosomes Chronic myelogenous leukemia that is Philadelphia chromosome – positive Chronic lymphocytic leukemia that is Philadelphia chromosome – negative
ANS: C Imatinib mesylate (Gleevec) is targeted therapy for chronic myelogenous leukemia (CML) that is Philadelphia chromosome – positive. This drug prevents the activation of an enzyme (tyrosine kinase) needed for the growth of CML cells that overexpress the abl oncogene. This expression is associated with the presence of one or more Philadelphia chromosomes in the leukemia cells. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A MSC: Client Needs Category: Physiological Integrity 38. Why is the transplantation of bone marrow cells separated from the preconditioning chemotherapy regimen by at least 2 days? A. To prevent a more profound neutropenic response B. To give the client a rest period before the vigorous therapeutic regimen begins C. To ensure all chemotherapy is cleared and cannot exert killing effects on the transplanted cells D. To allow the client to recover from the severe nausea and vomiting caused by the conditioning chemotherapy ANS: C Chemotherapy is systemic and nonspecific in its cytotoxic effects. Residual chemotherapy could kill off the transplanted cells. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A MSC: Client Needs Category: Safe, Effective Care Environment;
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39. The client with lymphoma who is considering a stem cell transplant asks what is the difference between a stem cell transplant and a bone marrow transplant. What is the nurse’s best response? A. “Bone marrow transplantation requires more chemotherapy and radiation than does stem cell transplantation.” B. “A bone marrow transplant is one type of stem cell transplant. The only difference is the source of the stem cells.” C. “A stem cell transplant is useful for solid tumor cancers, but a bone marrow transplant is needed for lymphoma.” D. “Cells for a stem cell transplant can come from a person other than a family member related by blood, but cells for a bone marrow transplant must come from a blood relative.” ANS: B The purpose of a stem cell transplant for cancer is to transplant undifferentiated stem cells into a client whose own stem cells for making blood cells have been destroyed by cytotoxic therapy. The bone marrow is a major source for stem cells. Other sources for stem cells are the peripheral blood and umbilical cord of newborn infants. Thus, a bone marrow transplant is a stem cell transplant. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Psychosocial Integrity 40. Which nursing diagnosis or collaborative problem has the highest priority for the bone marrow donor during the first 48 hours after the donation procedure? A. Acute Pain B. Risk for Infection C. Ineffective Coping D. Potential for leukemia ANS: A The donor of bone marrow has numerous punctures beneath the skin through the bone into the marrow. These areas usually cause the donor considerable discomfort for the first few days after the procedure. The risk for infection is no greater than with any invasive procedure performed on an immunocompetent person. The donor has usually undergone extensive psychological assessment and counseling before he or she agrees to donate. The procedure is not associated with an increased risk for leukemia. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;
Test Bank 41. What laboratory value indicates to the nurse that the conditioning regimen for bone marrow transplantation is successful? A. Total white blood cell count of 8000/mm 3 B. Total white blood cell count of 0/mm 3 C. Hematocrit of 25% D. Hematocrit of 50% ANS: B The purpose of pretransplantation conditioning is to "wipe out" the client's existing bone marrow cells. A circulating white blood cell count of 0 indicates successful conditioning. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Physiological Integrity 42. Which clinical manifestation during the actual bone marrow transplantation alerts the nurse to the possibility of an adverse reaction? A. Fever B. Red urine C. Hypertension D. Shortness of breath ANS: D Fever and hypertension are expected responses to the preservative used in the storage of the bone marrow stem cells. Red urine is expected as a consequence of hemolyzed red blood cells in the transfused product. Shortness of breath is not an expected client response and may indicate an adverse reaction. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Safe, Effective Care Environment;
Test Bank 43. At 6 weeks after bone marrow transplantation, a nurse observe that the client has rising white blood cell, erythrocyte, and platelet counts. What is the nurse’s interpretation of these findings? A. The transplant has engrafted. B. The client has a systemic infection. C. The leukemia is no longer in remission. D. The client has graft-versus-host disease. ANS: A Because the pretransplantation conditioning regimen has destroyed the client's own functional bone marrow, rising white blood cell, erythrocyte, and platelet counts indicate that the transplanted marrow has successfully implanted itself in the client's bones and is reproducing (engraftment). DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation/Analysis MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity; 44. Approximately 6 weeks after the client has received an allogeneic bone marrow transplant, a nurse notes that the client has peeling skin on the hands, feet, and legs. What is the nurse’s best first action? A. Request a humidifier to increase the moisture of the room. B. Apply lanolin-based creams to the client's skin. C. Document the observation as the only action. D. Notify the physician. ANS: D Peeling skin is an early indication of graft-versus-host disease, in which the transplanted cells attack host cells. Without intervention, this process can progress, causing extensive tissue damage and death. The client’s skin needs to be assessed and biopsied as soon as possible to initiate appropriate therapy. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation/Implementation/Intervention MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;
Test Bank 45. The client is 22 days post transplant from an allogeneic bone marrow transplantation. The nurse observes that the client's sclera and hard palate are yellow. Which additional clinical manifestation supports the possibility of veno-occlusive disease (VOD)? A. Weight gain of 8 pounds in the last 3 days B. Total white blood cell count of 2000 per mm 3 C. Six to 10 watery stools per day for the last 3 days D. Hard, ropelike consistency of the peripheral vein proximal to the IV site ANS: A VOD occludes hepatic venules through thrombosis and phlebitis. The resulting decreased liver function causes the formation of ascites, weight gain, increased abdominal girth, liver enlargement, and pain in the right upper quadrant. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment/Evaluation MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity; 46. The home care nurse observes a break in the catheter lumen while changing the central venous catheter dressing of a client after bone marrow transplantation. What is the nurse’s best first action? A. Document the observation. B. Cover the break with sterile tape. C. Remove the central venous catheter. D. Clamp the catheter proximal to the break. ANS: D The central venous catheter provides a direct line to the internal environment of a client at great risk for infection and bleeding. Protecting the client from infection after discharge is just as important as when the client was hospitalized. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;
Test Bank 47. The client being discharged home after a bone marrow transplantation for leukemia asks why protection from injury is so important. What is the nurse’s best response? A. “The transplanted bone marrow cells are very fragile and trauma could result in rejection of the transplant.” B. “Trauma is likely to result in loss of skin integrity, increasing the risk for infection when you are already immunosuppressed.” C. “Platelet recovery is slower than white blood cell recovery and you remain at risk longer for bleeding than you do for infection.” D. “The medication regimen after transplantation includes drugs that slow down cell division, making healing after any injury more difficult.” ANS: C Platelets recover more slowly than other blood cells after bone marrow transplantation. Thus, the client is still thrombocytopenic at home and remains at risk for excessive bleeding after any trauma of injury. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Health Promotion and Maintenance/Psychosocial Integrity 48. The client who has been diagnosed with Hodgkin's lymphoma is scheduled for numerous tests. The client asks if these tests are really necessary, because the exact type of cancer has already been established. What is the nurse’s best response? A. “You may be eligible for new and experimental therapy. These tests will determine whether or not you would qualify for such treatment.” B. “It is best to determine how healthy your major organs are before undergoing the strenuous and uncomfortable therapies for cancer.” C. “Different treatments are used depending on where the cancer is, so it is first necessary to determine the exact sites.” D. “The doctors want to be very sure, because it is possible to have two different kinds of cancer at the same time.” ANS: C Such great progress has been made in the treatment regimen that Hodgkin's lymphoma is now one of the most curable types of cancer. Staging procedures for determining disease location and extent are detailed and must be accurate, because the most appropriate treatment regimen is determined by the extent of the disease. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Psychological Integrity
Test Bank 49. The 27-year-old male client with Hodgkin's lymphoma in the abdominal and pelvic regions is about to start radiation therapy. What long-term side effect of this therapy should the nurse be sure that he understands? A. Sperm production will be permanently disrupted. B. Constipation will be continuous throughout therapy. C. Baldness from radiation therapy is likely to be permanent. D. This treatment increases the risk for prostate cancer later in life. ANS: A Only tissues in the actual radiation path are affected by this therapy. Radiation to the gonad area permanently damages the ability of the testes to produce fertile sperm. Diarrhea is more likely than constipation and no e vidence has suggested that the client’s risk for prostate cancer will be increased. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Implementation MSC: Client Needs Category: Psychosocial Integrity/Health Promotion and Maintenance 50. What is the priority nursing diagnosis for a client newly diagnosed with autoimmune thrombocytopenic purpura? A. Impaired Gas Exchange B. Impaired Skin Integrity C. Risk for Injury D. Acute Pain ANS: C This client has greatly decreased numbers of platelets because of their rapid and excessive destruction, placing the client at great risk for bleeding. Bleeding occurs with even minor trauma and may occur spontaneously. Pain is not a common manifestation at this stage of the disease. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Analysis MSC: Client Needs Category: Safe, Effective Care Environment;
Test Bank 51. Which laboratory test result indicates to the nurse that the factor VIII cryoprecipitate therapy for the client with hemophilia is effective? A. Hematocrit of 43% B. Platelet count of 200,000/mm 3 C. Prothrombin time of 15 seconds (INR of 1.3) D. Activated partial thromboplastin time of less than 30 seconds ANS: D The specific clotting problem resulting from insufficient amounts of factor VIII cause the activated partial thromboplastin time to be prolonged in clients with hemophilia. When administration of cryoprecipitated factor VIII is effective, the activated partial thromboplastin time is within the normal range. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Evaluation MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity; 52. How should the nurse modify the standard transfusion therapy procedure when administering a platelet transfusion? A. Use a transfusion set that has short tubing and no filter. B. Warm the platelets to body temperature before initiating the transfusion. C. Administer the platelet solution by rapid IV push instead of as an infusion. D. Co-administer amphotericin B as prophylaxis against fungal contamination. ANS: A Platelets are fragile and must be infused immediately after being brought to the client's room, usually over a 15- to 30-minute period. A special transfusion set with a smaller filter and shorter tubing is used. Standard transfusion sets are not used with platelets because the filter traps the platelets, and the longer tubing increases platelet adherence to the lumen. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Safe, Effective Care Environment;
Test Bank 53. A nurse observes that the client, whose blood type is AB negative, is receiving a transfusion with type O negative packed red blood cells. What is the nurse’s best first action? A. Call the blood bank. B. Take and record the client's vital signs. C. Stop the transfusion and keep the IV open. D. Document the observation as the only action. ANS: B Clients with AB-negative blood types can receive O-negative blood because they do not have antibodies against this type of blood. The transfusion can proceed. The nurse monitors the client’s vital signs as if he or she were receiving t ype AB-negative packed red blood cells. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Safe, Effective Care Environment; 54. What identification means should the nurse use to ensure that a blood transfusion is administered to the correct client? A. Ask the client if his name is the one on the blood product tag. B. Ask the client’s spouse if the client is the correct person who is to have the transfusion. C. Compare the name and ID number on the blood product tag with the name and ID number on the client’s ID band. D. Compare the bed and room number of the client with the bed and room number listed on the blood product tag. ANS: C The safest way to determine whether the blood product is about to be given to the correct client is to check the client’s hospital ID band an d compare the information on it with that on the blood product tag. The room and bed number are never considered as a means of positive identification. Asking the client who he or she is might result in an error if the client is confused. Likewise, a visitor cannot be assumed to know which client is which. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Safe, Effective Care Environment;
Test Bank 55. The client is prescribed to receive two units of packed red blood cells. When the blood products arrive, a nurse notes that the client's current IV is infusing Ringer's lactate solution. What should the nurse do in this situation? A. Change the intravenous solution to dextrose 5% in water. B. Hang the blood with the currently infusing solution. C. Change the intravenous solution to normal saline. D. Start an additional intravenous infusion site. ANS: C Blood and blood products can only be administered with normal saline. Other solutions hemolyze or clot the blood. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Safe, Effective Care Environment; 56. The client is receiving a unit of packed red blood cells. Fifteen minutes into the infusion, the client is cyanotic and complains of chest pain. What is the nurse’s best first action? A. Administer oxygen. B. Stop the transfusion. C. Call the emergency team. D. Increase the infusion flow rate. ANS: B It is most likely that the client is having a hemolytic transfusion reaction. The infusion should be stopped immediately, even before administering oxygen or calling the emergency team, to prevent a more severe reaction. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;
Test Bank 57. The older adult client is receiving the third unit of packed red blood cells that have been administered in the last 8 hours. One hour into the third transfusion, a nurse observes the client to have distended neck veins in the sitting position. What is the nurse’s best first action? A. Slow the infusion rate. B. Discontinue the transfusion. C. Document the observation as the only action. D. Check the type of infusing blood with the client's blood type. ANS: A Older adult clients are at risk for developing fluid overload during transfusion therapy, especially when receiving multiple units of packed red blood cells, which have a high osmotic pressure. The infusion rate should be slowed as low as possible, even before the client's circulatory status is assessed, to prevent worsening of the problem. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity; 58. For which of the following blood products is ABO compatibility a requirement for administration? A. Single-donor platelets B. Pooled donor platelets C. Fresh frozen plasma D. Granulocytes ANS: C Plasma contains AB antibodies and would be capable of causing a hemolytic transfusion reaction if the plasma were not ABO- compatible with the recipient’s blood type. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: N/A MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;
Test Bank 59. The client, a Jehovah's Witness scheduled for surgery, has expressed concern that she might receive blood products, an act condemned by her religion. What is the nurse’s best response? A. “You should allow the health care professionals to do whatever is needed to save your life.” B. “Your chances of needing a transfusion during or after surgery are so small that this is not really a problem.” C. “Transfusions are not routine and there are now good alternatives to transfusions if you should lose an excessive amount of blood.” D. “If you are worried about contamination, you could have members of your family make blood donations ahead of time specifi cally for you.” ANS: C The client's rights and wishes should be respected while providing accurate information for reassurance. Directed donations from family members neither ensure safe blood products nor are sanctioned by the client’s religion. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Psychosocial Integrity 60. Which type of transfusion reaction should the nurse assess for in the client who is receiving an autologous blood transfusion? A. Hemolytic B. Bacterial C. Allergic D. Febrile ANS: B When a client receives his or her own blood in a transfusion, compatibility problems, allergic reactions, and febrile transfusion responses are eliminated. However, this blood can become contaminated and cause a bacterial transfusion reaction. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;
Test Bank 61. For which client receiving a blood transfusion should the nurse remain especially alert for the possible development of transfusion-associated graft-versus-host disease (TA-GVHD)? A. 27-year-old pregnant woman with sickle cell anemia B. 45-year-old man on immunosuppressant therapy after a kidney transplant C. 68-year-old man receiving an autologous transfusion after hip replacement surgery D. 56-year-old woman who is AB-positive receiving a transfusion with O-negative blood products ANS: B Transfusion-associated graft-versus-host disease is rare but most likely to occur either in immunosuppressed transfusion recipients or immunocompetent recipients receiving blood donated by first-degree relatives. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity; OTHER
1. Indicate whether the following conditions or characteristics are most commonly associated with A. Acute lymphocytic leukemia B. Acute myelogenous leukemia C. Chronic lymphocytic leukemia D. Chronic myelogenous leukemia _____ Philadelphia chromosome _____ Most common type of leukemia among young adults _____ Responds to maintenance therapy _____ Has a familial or genetic predisposition _____ Occurs equally among men and women _____ CALLA-positive ANS: __C__ Philadelphia chromosome __B__ Most common type of leukemia among young adults __A__ Responds to maintenance therapy __D__ Has a familial or genetic predisposition __B__ Occurs equally among men and women __A__ CALLA-positive Rationale: The Philadelphia chromosome structural rearrangement is a marker for the diagnosis of CML and is a predictor of prognosis. Additionally, those clients whose CML is Philadelphia chromosome– positive are more likely to respond to Gleevec as targeted therapy. AML is the most common type of leukemia occurring in young adults. ALL is the most common type of leukemia found in children, and both CLL and CML usually do not occur in people under age 50. The only type of leukemia that appears to be able to be
Test Bank kept in remission with maintenance therapy is ALL. CLL has a genetic predisposition that appears to have an autosomal dominant pattern of inheritance. Concordance among identical twins is relatively high. ALL, CML, and CLL occur more frequently in males than among females. There is no gender specificity associated with the development of AML. Of all the types of leukemia, the only one that consistently shows the presence of CALLA (common acute lymphoblastic leukemia antigen) proteins on its cell surfaces is ALL. DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment MSC: Client Needs Category: Physiological Integrity
