Ch.

42
A nurse is caring for a client with sickle cell disease (SCD). Which action is most effective in reducing
the potential for sepsis in this client? Frequent and thorough handwashing = Prevention and early
detection strategies are used to protect the client in sickle cell crisis from infection. Frequent and
thorough handwashing is of the utmost importance.
What intervention most effectively protects a client with thrombocytopenia? Encouraging the
use of an electric shaver = The client should be advised to use an electric shaver instead of a razor.
Any small cuts or nicks can cause problems because of the prolonged clotting time.
Which client statement indicates that stem cell transplantation that is scheduled to take place in his
home is not a viable option? "I was a nurse, so I can take care of myself." = Stem cell
transplantation in the home setting requires support, assistance, and coordination from others. The
client cannot manage this type of care on his own. The client must be emotionally stable to be a
candidate for this type of care.
A nurse is to administer packed red blood cells to a client. How does the nurse ensure proper client
identification? Reviews all information with another registered nurse = With another registered
nurse, verify the client by name and number, check blood compatibility, and note expiration time.
Human error is the most common cause of ABO incompatibility reactions, even for experienced
nurses.
A nurse is teaching a group of teens about cancer risks. What does the nurse stress as the most
important environmental risk for developing leukemia? Smoking cigarettes = According to the
American Cancer Society, the only proven lifestyle-related risk factor for leukemia is cigarette
smoking.
A client who has been newly diagnosed with leukemia is admitted to the hospital. Avoiding which
potential problem takes priority in the client's nursing care plan? Infection = The main objective in
caring for a newly diagnosed client with leukemia is protection from infection.
A nurse is assessing the endurance level of a client in a long-term care facility. What question does the
nurse ask to get this information? "Do you feel more tired after you get up and go to the
bathroom?" = This question is pertinent to the client's activity and provides a comparison. The specific
activity helps the client relate to the question and provide needed answers.
A nurse is teaching a client with vitamin B12 deficiency anemia about dietary intake. Which type of
food does the nurse encourage the client to eat? Dairy products = Dairy products such as milk,
cheese, and eggs will provide the vitamin B12 that the client needs.
A nurse is teaching a client about induction therapy for acute leukemia. Which client statement
indicates a need for additional education? "After this therapy, I will not need to have any more." =
Induction therapy is not a cure for leukemia, it is a treatment.

A client with multiple myeloma reports bone pain that is unrelieved by analgesics. How does the nurse
respond to this client's problem? "Would you like to try some relaxation techniques?" = Because
most clients with multiple myeloma have local or generalized bone pain, analgesics and alternative
approaches for pain management, such as relaxation techniques, are used for pain relief. This also
offers the client a choice.
What are the risk factors for the development of leukemia? Select all that apply.
Bone marrow hypoplasia Correct
Chemical exposure Correct
Down syndrome Correct
Ionizing radiation Correct
Wheezes or crackles in the neutropenic client may be the first symptom of infection in the lungs.

A nurse is caring for a client with neutropenia who has a suspected infection. Which intervention does
the nurse implement first? Obtaining cultures to identify the infectious agent correctly is the priority
for this client.
The client with thrombocytopenia has a high risk for bleeding. The nosebleed should be attended to
immediately.
Hemolytic transfusion reactions are caused by blood type or Rh incompatibility. When blood that
contains antigens different from the client's own antigens is infused, antigen-antibody complexes are
formed in the client's blood. Type O is considered the universal donor but not the universal
recipient.
During transfusion, some cells are damaged. These cells release potassium, thus raising the client's
serum potassium level (hyperkalemia). This complication is especially common with packed cells and
whole blood products.
A nurse is infusing platelets to a client who is scheduled for a hematopoietic stem cell transplant
(HSCT). What procedure does the nurse follow? Infuses the transfusion over a 15- to 30-minute
period = The volume of platelets-200 or 300 mL (standard amount)-needs to be infused rapidly-over a
15- to 30-minute period.
An 82-year-old client with anemia is requested to receive 2 units of whole blood. Which assessment
finding causes the nurse to discontinue the transfusion because it is unsafe for the client? Select all
that apply. Hypertension Hypotension Rapid, bounding pulse Correct Correct Correct
Because clients with aplastic anemia usually have low white blood cell counts that place them at
high risk for infection, roommates such as the client with G6PD anemia should be free from infection or
infection risk.
Waits until the transfusion has been completed to administer Lasix. = This is the best course of action
in the scenario. The nurse should not administer Lasix while the blood is infusing. Stopping the infusing
blood to administer the drug-and then re-starting it-is also not the best decision.
The client is a 56-year-old man admitted with a diagnosis of acute myelogenous leukemia (AML). He is
prescribed IV cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. What
is the major side effect of this therapy? Bone marrow suppression = This is a commonly prescribed
course of aggressive chemotherapy, and bone marrow suppression is a major side effect. The client is
even more at risk for infection than before treatment was begun.
The client is a 56-year-old man admitted with a diagnosis of acute myelogenous leukemia (AML). He is
prescribed IV cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. He
develops an infection. What knowledge does the nurse use to determine that the appropriate
antibiotic has been prescribed for this client? Checking the culture and sensitivity test results to be
certain that the requested antibiotic is effective against the organism causing the infection = Drug
therapy is the main defense against infections that develop in clients undergoing therapy for AML.
Agents used depend on the client's sensitivity to various antibiotics for the organism causing the
infection.
A 56-year-old man is admitted with a diagnosis of acute myelogenous leukemia (AML). He is
prescribed IV cytosine arabinoside for 7 days and an infusion of daunorubicin for the first 3 days. He is
started on an antiviral agent. What are serious side effects of antiviral agents? Nephrotoxicity,
Ototoxicity Stroke. , and





Ch.41

A client is scheduled for a bone marrow aspiration. What does the client's nurse do before taking the
client to the treatment room for the biopsy? Verifying informed consent must be done before the
procedure can be performed. A signed permit must be on the client's chart.
A nurse is assessing an adult client's endurance in performing ADLs. What question does the nurse ask
the client? "How is your energy level-compared with last year?" This question from Gordon's
Functional Health Pattern Assessment is an activity exercise question that correctly assesses
endurance compared with self-assessment in the past. It is most likely to provide data about the
client's ability and endurance with ADLs.
A nurse is assessing a client for hematologic function risks. The nurse seeks to determine whether there
is a risk that cannot be reduced or eliminated. Which clinical health history question does the nurse
ask to obtain this information? "Does anyone in your family bleed a lot?" An accurate family
history is important because many disorders that affect blood and blood clotting are inherited.
Genetics cannot be changed.
A nurse is teaching a client about what to expect during a bone marrow biopsy. Which statement by
the nurse accurately describes the procedure? "You may experience a crunching sound or a
scraping sensation as the needle punctures your bone." This description is accurate. Proper
expectations minimize the client's fear during the procedure.
A client with anemia asks, "Why am I feeling tired all the time?" How does the nurse respond? "Your
cells are delivering less oxygen than you need." The single most common symptom of anemia is
fatigue. This problem occurs because oxygen delivery to cells is less than is required to meet normal
oxygen needs.
A nurse is reviewing complete blood count (CBC) data for a 76-year-old client. Which decreased
value causes concern because it is not age related? Platelet counts do not generally change with
age.
A client with a low platelet count asks why platelets are important. How does the nurse answer?
"The clotting process begins with your platelets." Platelets begin the blood clotting process by forming
platelet plugs, but these platelet plugs are not clots and cannot provide complete hemostasis.
A newly admitted client has an elevated reticulocyte count. Which disorder does the nurse suspect in
this client? Hemolytic anemia An elevated reticulocyte count in the anemic client indicates that
the bone marrow is responding appropriately to a decrease in the total red blood cell (RBC) mass
and is prematurely destroying red blood cells. Therefore more immature RBCs are in circulation.
Anticoagulants work by interfering with one or more steps involved in the blood clotting cascade.
Thus, these agents prevent new clots from forming and limit or prevent extension of formed clots.
A nurse is caring for a group of hospitalized clients. Which client is at greatest risk for infection and
sepsis? 18-year-old who had an emergency splenectomy. Removal of the spleen causes the
client to have reduced immune function. Without a spleen, people are less able to remove disease-
causing organisms.
A nurse is assessing the nutritional status of a client with anemia. How does the nurse obtain
information about the client's diet? Has the client write down everything he or she has eaten for
the past week.
A clinic nurse is discharging a 20-year-old client who had a bone marrow aspiration performed. What
does the nurse advise the client to do? Place an ice pack over the site to reduce the bruising."
Ice to the site will help limit bruising and tissue damage during the first 24 hours postprocedure.
Which client does the medical unit charge nurse assign to an LPN/LVN? 48-year-old with chronic
microcytic anemia associated with alcohol use This client has a chronic condition that is not
considered life threatening.
A bone marrow biopsy with conscious sedation requires more complex assessment or nursing care
and should be assigned to RN staff members.
A history of a splenectomy and a temperature require more complex assessment or nursing care and
should be assigned to RN staff members.
Atrial fibrillation and an international normalized ratio (INR) of 6.6 require more complex assessment or
nursing care and should be assigned to RN staff members.
Reporting findings during routine care is expected and required of unlicensed staff members.
59-year old who has a nosebleed and is receiving heparin to treat a pulmonary embolism = This client
may be experiencing the bleeding as a result of excessive anticoagulation and should be assessed for
the severity of the situation before the other clients, whose conditions are stable, are assessed.
After reviewing the laboratory test results, the nurse calls the health care provider about which
client? 46-year-old with a fever and a white blood cell (WBC) count of 500/l This client is
neutropenic and is at risk for sepsis unless interventions such as medications to improve WBC level and
antibiotics are prescribed.
The INR of 3.0 indicates a therapeutic Coumadin level.
An elevated reticulocyte count is expected after hemorrhage.
A client has a bone marrow biopsy done. Which nursing intervention is the priority postprocedure?
Applying pressure to the biopsy site The initial action should be to stop bleeding by applying pressure
to the site.