Chapter 33: Nursing Management: Hematological Problems

Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition

MULTIPLE CHOICE

1. The nurse is caring for a client with anemia who is experiencing increased fatigue and occasional palpitations at rest. Which of the
following laboratory findings should the nurse expect?
a. Normal red blood cell (RBC) indices
b. Hematocrit (Hct) of 38%
c. Hemoglobin (Hb) of 86 g/L
d. RBC count of 4.5 × 1012/L
ANS: C
The client’s clinical manifestations indicate moderate anemia, which is consistent with an Hb of 60–100 g/L. The other values are
all within the range of normal.

DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment

2. Which of the following menu choices indicate that the client understands the nurse’s teaching about best dietary choices for
iron-deficiency anemia?
a. Omelette and whole wheat toast
b. Cantaloupe and cottage cheese
c. Strawberry and banana fruit plate
d. Cornmeal muffin and orange juice
ANS: A
Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies, but are not the
best choice for a client with iron-deficiency anemia.

DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation

3. The nurse is caring for a client who is receiving methotrexate and develops a megaloblastic anemia. Which of the following
nutrients should the nurse include in the teaching plan?
a. Iron
b. Folic acid
c. Cobalamin (vitamin B12)
d. Ascorbic acid (vitamin C)
ANS: B
Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The
other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.

DIF: Cognitive Level: Application TOP: Nursing Process: Planning

4. The nurse is teaching a client with a new diagnosis of pernicious anemia about the disorder. Which of the following client
statements indicates that the teaching has been effective?
a. “I need to start eating more red meat or liver.”
b. “I will stop having a glass of wine with dinner.”
c. “I will need to take a proton pump inhibitor like omeprazole.”
d. “I would rather use the nasal spray than have to get injections of vitamin B 12.”

ANS: D
Since pernicious anemia prevents the absorption of vitamin B12, this client requires injections or intranasal administration of
cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B 12.
Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.

DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation

5. The nurse is caring for a client who is hospitalized for treatment of severe hemolytic anemia. Which of the following actions should
the nurse implement?
a. Provide a diet high in vitamin K.
b. Place the client on protective isolation.
c. Alternate periods of rest and activity.
d. Teach the client how to avoid injury.
ANS: C
Nursing care for clients with anemia should alternate periods of rest and activity to encourage activity without causing undue
fatigue. There is no indication that the client has a bleeding disorder, so a high vitamin K diet or teaching about how to avoid injury
is not needed. Protective isolation might be used for a client with aplastic anemia, but it is not indicated for hemolytic anemia.

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

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 6. The nurse has finished teaching a client about taking oral ferrous sulphate. Which of the following client statements indicates that
additional instruction is needed?
a. “I will call the doctor if my stools start to turn black.”
b. “I will take a stool softener if I feel constipated occasionally.”
c. “I should take the iron with orange juice about an hour before eating.”
d. “I should increase my fluid and fibre intake while I am taking the iron tablets.”
ANS: A
It is normal for the stools to appear black when a client is taking iron and the client should not call the doctor about this. The other
client statements are correct.

DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation

7. The nurse is caring for a client with idiopathic aplastic anemia. Which of the following collaborative problems should the nurse
include when developing the care plan?
a. Potential complication: seizures
b. Potential complication: infection
c. Potential complication: neurogenic shock
d. Potential complication: pulmonary edema
ANS: B
Because the client with aplastic anemia has pancytopenia, the client is at risk for infection and bleeding. There is no increased risk
for seizures, neurogenic shock, or pulmonary edema.

DIF: Cognitive Level: Application TOP: Nursing Process: Planning

8. The nurse is caring for a client with a sickle cell crisis. While caring for the client during the crisis, which of the following actions
is priority?
a. Limit the client’s intake of oral and IV fluids.
b. Evaluate the effectiveness of opioid analgesics.
c. Encourage the client to ambulate as much as tolerated.
d. Teach the client about high-protein, high-calorie foods.
ANS: B
Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid
intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic
requirements. Clients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized.

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

9. Which of the following statements by a client with sickle cell anemia indicates good understanding of the nurse’s teaching about
prevention of sickle cell crisis?
a. “Home oxygen therapy is frequently used to decrease sickling.”
b. “There are no effective medications that can help prevent sickling.”
c. “Routine continuous dosage narcotics are prescribed to prevent a crisis.”
d. “Risk for a crisis can be lowered by having an annual influenza vaccination.”
ANS: D
Since infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and
hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a
crisis, clients do not receive these therapies to prevent crisis. Hydroxyurea is used for many clients to decrease the number of
sickle cell crises.

DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation

10. The nurse is planning discharge teaching for a client who was admitted with neutropenia. Which of the following instructions
should the nurse include?
a. Limit fluids to 2–3 litres a day.
b. Include eggs and fish in the diet.
c. Avoid exposure to crowds as much as possible.
d. Drink only one or two caffeinated beverages daily.
ANS: C
Exposure to crowds increases the client’s risk for infection and should be avoided for the client with neutropenia. There is no
restriction on caffeine use. Iron supplementation is generally not recommended. A high-fluid intake is recommended. Eggs and
seafood are to be avoided.

DIF: Cognitive Level: Application TOP: Nursing Process: Planning

11. The nurse is admitting a client with hemolytic anemia and notes jaundice of the sclerae. Which of the following laboratory results
should the nurse assess?
a. Schilling test
b. Bilirubin level
c. Stool occult blood test
d. Gastric analysis testing
ANS: B
Jaundice is caused by the elevation of bilirubin level associated with red blood cell (RBC) hemolysis. The other tests would not be
helpful in monitoring or treating a hemolytic anemia.

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 12. The nurse is caring for a client who has been receiving a heparin infusion and warfarin for a deep vein thrombosis (DVT) with a
diagnosis of heparin-induced thrombo-cytopenia (HIT). Which of the following actions should the nurse include in the plan of
care?
a. Use low-molecular-weight heparin (LMWH) only.
b. Flush all intermittent IV lines using normal saline.
c. Administer the warfarin at the scheduled time.
d. Teach the client about the purpose of platelet transfusions.
ANS: B
All heparin is discontinued when the HIT is diagnosed. The client should be instructed to never receive heparin or LMWH.
Warfarin is usually not given until the platelet count has returned to 150 × 109/L. The platelet count does not drop low enough in
HIT for a platelet transfusion, and platelet transfusions increase the risk for thrombosis.

DIF: Cognitive Level: Application TOP: Nursing Process: Planning

13. The nurse is caring for a client with an acute exacerbation of polycythemia vera. Which of the following actions should the nurse
implement during treatment?
a. Place the client on bed rest.
b. Administer iron supplements.
c. Avoid use of Aspirin products.
d. Monitor fluid intake and output.
ANS: D
Monitoring hydration status is important during an acute exacerbation because the client is at risk for fluid overload or
underhydration. Aspirin therapy is used to decrease risk for thrombosis. The client should be encouraged to ambulate to prevent
deep vein thrombosis (DVT). Iron is contraindicated in clients with polycythemia vera.

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

14. Which of the following nursing interventions should be included in the care plan for a client with immune thrombo-cytopenic
purpura (ITP)?
a. Assign the client to a private room.
b. Avoid intramuscular (IM) injections.
c. Use rinses rather than a toothbrush for oral care.
d. Restrict activity to passive and active range of motion.
ANS: B
IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care.
There is no need to restrict activity or place the client in a private room.

DIF: Cognitive Level: Application TOP: Nursing Process: Planning

15. Which of the following laboratory information should the nurse monitor to detect heparin-induced thrombo-cytopenia (HIT) in a
client who is receiving a continuous heparin infusion?
a. Prothrombin time
b. Erythrocyte count
c. Fibrinogen degradation products
d. Activated partial thromboplastin time
ANS: D
Platelet aggregation in HIT causes neutralization of heparin, so that the activated partial thromboplastin time will be shorter and
more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.

DIF: Cognitive Level: Application TOP: Nursing Process: Assessment

16. The nurse is admitting a client with type A hemophilia who has severe pain and swelling in the right knee. Which of the following
actions should the nurse implement initially?
a. Immobilize the knee
b. Apply heat to the joint
c. Assist the client with light weight bearing
d. Perform passive range of motion to the knee
ANS: A
The initial action should be total rest of the knee to minimize bleeding. Ice packs are used to decrease bleeding. Range-of-motion
(ROM) and weight-bearing exercise are contraindicated initially, but after the bleeding stops, ROM and physical therapy are
started.

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

17. The nurse is caring for a client with von Willebrand disease who is admitted to the hospital for minor knee surgery. Which of the
following laboratory information should the nurse assess?
a. Platelet count
b. Bleeding time
c. Thrombin time
d. Prothrombin time
ANS: B
The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von
Willebrand disease.

DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment

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 18. A routine complete blood count indicates that a client may have myelodysplastic syndrome. At this time, which of the following
information should the nurse include in the teaching plan?
a. Packed red blood cells (PRBCs) transfusion
b. Bone marrow biopsy
c. Filgrastim administration
d. Erythropoietin administration
ANS: B
Bone marrow biopsy is needed to make the diagnosis and determines the specific type of myelodysplastic syndrome. The other
treatments may be necessary if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic
client will be a bone marrow biopsy.

DIF: Cognitive Level: Application TOP: Nursing Process: Planning

19. Which of the following actions should the nurse include in the care plan for a hospitalized client who is neutropenic?
a. Avoid any IM or subcutaneous injections.
b. Check the oral temperature every 4 hours.
c. Omit all fruits or vegetables from the diet.
d. Place a “No Visitors” sign on the client door.
ANS: B
The earliest sign of infection in a neutropenic client is an elevation in temperature. Although unpeeled fresh fruits and vegetables
should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of
medications such as filgrastim. The number of visitors may be limited and visitors with communicable diseases should be avoided,
but a “no visitors” policy is not needed.

DIF: Cognitive Level: Application TOP: Nursing Process: Planning

20. Which of the following laboratory tests should the nurse use to determine whether the prescribed filgrastim is effective in the
treatment of a client who is receiving chemotherapy for acute lymphocytic leukemia?
a. Platelet count
b. Reticulocyte count
c. Total lymphocyte count
d. Absolute neutrophil count
ANS: D
Filgrastim increases the neutrophil count and function in neutropenic clients. Although total lymphocyte, platelet, and reticulocyte
counts also are important to monitor in this client, the absolute neutrophil count is used to evaluate the effects of filgrastim.

DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation

21. The nurse is caring for a client with acute myelogenous leukemia (AML) who has induction therapy prescribed and the client asks
the nurse whether the planned chemotherapy will be worth undergoing. Which of the following responses by the nurse is best?
a. “If you do not want to have chemotherapy, there are other options for treatment
such as stem cell transplantation.”
b. “The decision about chemotherapy is one that you and the doctor need to make
rather than asking what I would do.”
c. “You don’t need to make a decision about treatment right now since leukemias in
adults tend to progress quite slowly.”
d. “The adverse effects of the chemotherapy are difficult, but AML frequently does
go into remission with chemotherapy.”
ANS: D
This response uses therapeutic communication by addressing the client’s question and giving accurate information. The other
responses either give inaccurate information or fail to address the client’s question, which will discourage the client from asking the
nurse for information.

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

22. The nurse is caring for a client who has a history of a transfusion-related acute lung injury (TRALI) and is to receive a transfusion
of packed red blood cells (PRBCs). Which of the following actions should the nurse take to decrease the risk for TRALI for this
client?
a. Infuse the PRBCs slowly over 4 hours.
b. Transfuse only leukocyte-reduced PRBCs.
c. Administer the scheduled oral diuretic before the transfusion.
d. Give the PRN dose of antihistamine before starting the transfusion.
ANS: B
TRALI is caused by a reaction between the donor and the client leukocytes that causes pulmonary inflammation and capillary
leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they
will not prevent TRALI.

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

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 23. The nurse is caring for a client with acute myelogenous leukemia (AML) who is considering the possibility of treatment with a
hematopoietic stem cell transplant (HSCT). Which of the following actions is best for the nurse to implement to assist the client
with treatment decisions?
a. Emphasize the positive outcomes of a bone marrow transplant.
b. Discuss the need for adequate insurance to cover post-HSCT care.
c. Ask the client whether there are any questions or concerns about HSCT.
d. Explain that a cure is not possible with any other treatment except HSCT.
ANS: C
Offering the client an opportunity to ask questions or discuss concerns about HSCT will encourage the client to voice
concerns about this treatment and also will allow the nurse to assess whether the client needs more information about the
procedure. Treatment of AML using chemotherapy is another option for the client. It is not appropriate for the nurse to ask the
client to consider insurance needs in making this decision.

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

24. Which of the following nursing actions should the nurse include in the plan of care for a client admitted with multiple myeloma?
a. Monitor fluid intake and output.
b. Administer calcium supplements.
c. Assess lymph nodes for enlargement.
d. Limit weight bearing and ambulation.
ANS: A
A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure
caused by deposition of Bence Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone
retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the client’s
calcium level and are not used.

DIF: Cognitive Level: Application TOP: Nursing Process: Planning

25. The nurse is caring for a client with non-Hodgkin’s lymphoma who develops a platelet count of 38 × 109/L during chemotherapy.
Which of the following actions should the nurse implement based on this finding?
a. Provide oral hygiene every 2 hours
b. Check all stools for occult blood
c. Assess temperature every 4 hours
d. Encourage fluids to 3 000 mL/day
ANS: B
Because the client is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not
require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low
platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

26. The nurse is caring for a client with acute myelogenous leukemia who is receiving outpatient chemotherapy and develops an
absolute neutrophil count of 0.9 × 109/L. Which of the following actions by the nurse in the outpatient clinic is best?
a. Discuss the need for hospital admission to treat the neutropenia.
b. Plan to discontinue the chemotherapy until the neutropenia resolves.
c. Teach the client how to administer filgrastim injections at home.
d. Obtain a high-efficiency particulate air (HEPA) filter for the client for home use.
ANS: C
The client may be taught to self-administer filgrastim injections. Although chemotherapy may be stopped with severe neutropenia
(neutrophil count less than 0.5 × 109/L), administration of filgrastim usually allows the chemotherapy to continue. Clients with
neutropenia are at higher risk for infection when exposed to other clients in the hospital. HEPA filters are expensive and are used in
the hospital, where the number of pathogens is much higher than in the client’s home environment.

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

27. Which of the following assessment data obtained by the nurse when caring for a client with thrombo-cytopenia should be
immediately communicated to the health care provider?
a. The platelet count is 52 × 109/L.
b. The client is difficult to arouse.
c. There are large bruises on the back.
d. There are purpura on the oral mucosa.
ANS: B
Difficulty in arousing the client may indicate a cerebral hemorrhage, which is life threatening and requires immediate action. The
other information should be documented and reported, but would not be unusual in a client with thrombo-cytopenia.

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 28. When a febrile episode occurs in a client with neutropenia, at what time should antibiotic therapy be initiated?
a. Within 1 hour
b. After the causative agent is identified from the culture
c. Once the fever drops below 38°C (100.4°F)
d. For long-term therapy over 3 months
ANS: A
When a febrile episode occurs in a client with neutropenia, antibiotic therapy must be initiated immediately (within 1 hour), even
before the determination by culture of a specific causative organism. Treatment does not wait until the fever drops. Long-term
therapy over 3 months is not required at this time.

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

29. The nurse is caring for a client receiving a transfusion of packed red blood cells who develops chills, fever, headache, and anxiety
30 minutes after the transfusion is started. After stopping the transfusion, which of the following actions is priority?
a. Draw blood for a new crossmatch.
b. Send a urine specimen to the laboratory.
c. Give the PRN diphenhydramine.
d. Administer the PRN acetaminophen.
ANS: D
The client’s clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be
stopped and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is
suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

30. Fifteen minutes after a transfusion of packed red blood cells is started, a client has symptoms of back pain and dyspnea and a pulse
rate of 124 beats/minute. Which of the following actions should the nurse implement initially?
a. Administer oxygen therapy at a high flow rate.
b. Obtain a urine specimen to send to the laboratory.
c. Notify the health care provider about the symptoms.
d. Disconnect the transfusion and infuse normal saline.
ANS: D
The client’s symptoms indicate a possible acute hemolytic reaction caused by the transfusion. The first action should be to
disconnect the transfusion and infuse normal saline. The other actions also are needed but are not the highest priority.

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

31. Which of the following newly admitted clients should the nurse assign as a roommate for a client who has aplastic anemia?
a. A client with severe heart failure
b. A client who has viral pneumonia
c. A client who has right leg cellulitis
d. A client with multiple abdominal drains
ANS: A
Clients with aplastic anemia are at risk for infection because of the low white blood cell production associated with this type of
anemia, so the nurse should avoid assigning a roommate with any possible infectious process.

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

32. The nurse is caring for a client with immune thrombo-cytopenic purpura (ITP) who has a prescription for a platelet transfusion.
Which of the following client information indicates that the nurse should consult with the health care provider before administering
platelets?
a. The platelet count is 42 × 109/L.
b. Blood pressure is 94/56 mm Hg.
c. Blood is oozing from the venipuncture site.
d. Petechiae are present on the chest and back.
ANS: A
Platelet transfusions are not usually indicated until the platelet count is below 10 × 109/L unless the client is actively bleeding, so
the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that
bleeding caused by ITP may be occurring and indicate that the platelet transfusion is appropriate.

DIF: Cognitive Level: Application TOP: Nursing Process: Assessment

33. The hemophilia clinic nurse receives a call from a client with hemophilia to discuss all of these problems. Which of the following
problems is most important to communicate to the health care provider?
a. Skin abrasions
b. Bleeding gums
c. Multiple bruises
d. Dark tarry stools
ANS: D
Melena is a sign of gastrointestinal bleeding and requires collaborative actions such as checking hemoglobin and hematocrit and
administration of coagulation factors. The other problems indicate a need for client teaching about how to avoid injury, but are not
indicators of possible serious blood loss.

DIF: Cognitive Level: Application TOP: Nursing Process: Assessment

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 34. The nurse is caring for a client with septicemia who develops prolonged bleeding from venipuncture sites and blood in the stools.
Which of the following actions is most important for the nurse to take?
a. Notify the client’s health care provider.
b. Avoid unnecessary venipunctures.
c. Apply sterile dressings to the sites.
d. Give prescribed proton-pump inhibitors.
ANS: A
The client’s new onset of bleeding and diagnosis of sepsis suggest that disseminated intravascular coagulation (DIC) may have
developed, which will require collaborative actions such as diagnostic testing, blood product administration, and heparin
administration. The other actions also are appropriate, but the most important action should be to notify the physician so that DIC
treatment can be initiated rapidly.

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

35. The nurse is caring for a client with myelodysplastic syndrome who has 20% blasts in marrow and the health care provider has
prescribed high-intensity treatment. Which of the following treatments should the nurse prepare the client to receive?
a. Antibiotics
b. Antifungals
c. Chemotherapy
d. A blood transfusion
ANS: C
Low-risk clients (<5% blasts in marrow) can often be treated with transfusions, antibiotics, antifungals, EPO, and hematopoietic
growth factors. High-risk clients (>5% blasts in marrow) may be treated with single-agent chemotherapy (e.g., hydroxyurea) or
intensive chemotherapy as in AML.

DIF: Cognitive Level: Application TOP: Nursing Process: Planning

36. The nurse is caring for a client with neutropenia who is started on an aminoglycoside. Which of the following common adverse
effects should the nurse observe for in the client?
a. Rash
b. Ototoxicity
c. Fever
d. Pruritus
ANS: B
Adverse effects common to aminoglycosides include nephrotoxicity and ototoxicity.
Adverse effects common to cephalosporins include rashes, fever, and pruritus.

DIF: Cognitive Level: Application TOP: Nursing Process: Assessment

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