Hematologic Disorders
The nurse reviews a patient’s lab results: Hgb 8.1 g/dL, MCV low, and ferritin decreased. Which condition does the nurse suspect?
A. Vitamin B12 deficiency anemia
B. Iron-deficiency anemia
C. Sickle cell anemia
D. Anemia of chronic disease
B. Iron-deficiency anemia
Rationale: Low hemoglobin, mean corpuscular volume (MCV), and ferritin indicate microcytic, hypochromic anemia caused by insufficient iron stores. Vitamin B12 deficiency causes macrocytosis instead.
A 2-year-old suddenly begins coughing and gagging while eating peanuts. The child is alert but wheezing and struggling to breathe. What is the nurse’s priority action?
A. Encourage the child to cough forcefully.
B. Perform blind finger sweep.
C. Give back blows immediately.
D. Begin rescue breathing.
A. Encourage the child to cough forcefully.
Rationale: If the child is conscious and able to cough or breathe, do not interfere—encourage effective coughing to expel the object. Blind sweeps can push the object deeper into the airway.
Which assessment finding is most consistent with brain death according to the Uniform Determination of Death Act (UDDA)?
A. Absent corneal and pupillary reflexes with no spontaneous respirations during apnea testing
B. Deep coma with sluggish pupillary response and occasional gasping
C. No verbal response but withdrawal to painful stimuli
D. Fixed pupils with preserved cough and gag reflex
A. Absent corneal and pupillary reflexes with no spontaneous respirations during apnea testing
Rationale: Brain death is confirmed when there is irreversible loss of all brain and brainstem activity, including absent brainstem reflexes and no respiratory effort despite elevated CO₂ during the apnea test.
The nurse is caring for a patient who is scheduled for an autologous stem cell transplant. Which statement accurately describes this procedure?
A. Stem cells are collected from a matched donor before chemotherapy.
B. The patient receives their own stem cells after intensive chemotherapy.
C. Stem cells are obtained from umbilical cord blood.
D. Stem cells from a sibling are infused after immunosuppression.
B. The patient receives their own stem cells after intensive chemotherapy.
Rationale: Autologous transplants use the patient’s own previously collected stem cells after high-dose chemotherapy or radiation. This reduces the risk of rejection and graft-versus-host disease (GVHD).
A patient who recently underwent an allogenic bone marrow transplant reports a new erythematous rash on the hands and feet, severe diarrhea, and elevated liver enzymes. Which complication should the nurse suspect?
A. Acute graft rejection
B. Cytomegalovirus infection
C. Graft-versus-host disease (GVHD)
D. Veno-occlusive disease (VOD)
C. Graft-versus-host disease (GVHD)
Rationale: In allogenic transplants, donor T-lymphocytes attack host tissues, commonly involving the skin, GI tract, and liver. Rash, diarrhea, and ↑ LFTs are hallmark findings. Treated with immunosuppressants (e.g., tacrolimus, methotrexate).
The nurse is caring for a patient with sickle cell crisis. Which intervention is the highest priority?
A. Restrict fluids to prevent overload.
B. Administer oxygen and encourage hydration.
C. Apply cold packs to painful joints.
D. Limit opioid use to prevent dependence.
B. Administer oxygen and encourage hydration.
Rationale: Oxygen and IV/oral fluids reduce RBC sickling and vaso-occlusion. Cold causes vasoconstriction and worsens ischemia. Adequate pain control is also crucial but secondary to perfusion and oxygenation.
A 6-year-old is admitted after falling from a tree and striking his head. He is drowsy, has unequal pupils, and vomited twice. What is the nurse’s priority action?
A. Observe for 30 minutes and reassess.
B. Keep NPO and notify the provider immediately.
C. Offer fluids to prevent dehydration.
D. Administer acetaminophen for headache.
B. Keep NPO and notify the provider immediately.
Rationale: Unequal pupils and vomiting are signs of increased intracranial pressure (ICP) from possible traumatic brain injury (TBI). The nurse should maintain NPO, elevate the head of the bed, and alert the provider for possible neuroimaging.
A patient is identified as a potential organ donor following declaration of brain death. Which nursing action is most important to maintain organ viability?
A. Discontinue all IV fluids to prevent edema.
B. Maintain normothermia and adequate blood pressure with fluid and vasopressor support.
C. Lower FiO₂ to avoid oxygen toxicity.
D. Administer corticosteroids to hasten organ recovery.
B. Maintain normothermia and adequate blood pressure with fluid and vasopressor support.
Rationale: Donor management goals include maintaining hemodynamic stability, oxygenation, and normothermia to preserve organ perfusion until recovery. Hypotension and hypoxia rapidly damage organs.
Which donor type carries the highest risk for graft-versus-host disease (GVHD)?
A. Autologous donor
B. Identical twin (isograft)
C. Matched unrelated donor (MUD)
D. Sibling matched donor
C. Matched unrelated donor (MUD).
Rationale: Although HLA-matched siblings have the best compatibility, matched unrelated donors carry a higher GVHD risk due to minor antigen mismatches despite close tissue typing.
The nurse is preparing to administer tacrolimus to a liver transplant recipient. Which assessment finding requires immediate provider notification?
A. BP 150/88 mm Hg
B. Serum creatinine 2.5 mg/dL
C. Blood glucose 132 mg/dL
D. Mild hand tremor
B. Serum creatinine 2.5 mg/dL
Rationale: Tacrolimus, a calcineurin inhibitor, is nephrotoxic. Rising creatinine indicates possible renal injury or drug toxicity. The medication may need to be adjusted to prevent permanent kidney damage.
A patient with heparin-induced thrombocytopenia (HIT) develops a DVT. Which action should the nurse take first?
A. Administer warfarin.
B. Continue heparin but reduce the dose.
C. Discontinue all heparin and start argatroban as prescribed.
D. Give platelet transfusion immediately.
C. Discontinue all heparin and start argatroban as prescribed.
Rationale: Heparin must be stopped immediately in HIT because antibodies activate platelets and promote thrombosis. A direct thrombin inhibitor (e.g., argatroban) prevents further clotting. Warfarin and platelet transfusions are contraindicated initially.
Which finding is most characteristic of shaken baby syndrome (abusive head trauma)?
A. Linear skull fracture and nasal bleeding
B. Retinal hemorrhages and lethargy without external injury
C. Vomiting with dehydration signs
D. Battle’s sign and raccoon eyes
B. Retinal hemorrhages and lethargy without external injury.
Rationale: Shaken baby syndrome typically presents with retinal hemorrhages, seizures, irritability, or lethargy, often without external trauma, due to repetitive acceleration-deceleration injury causing intracranial bleeding.
A nurse caring for a post–renal transplant patient notes a temperature of 101°F (38.3°C), pain over the graft site, and decreasing urine output. What is the nurse’s priority action?
A. Increase oral fluid intake.
B. Notify the transplant team immediately.
C. Hold the next dose of tacrolimus.
D. Encourage the patient to ambulate.
B. Notify the transplant team immediately.
Rationale: These findings indicate possible acute graft rejection (fever, graft tenderness, organ dysfunction). Prompt evaluation and treatment with high-dose corticosteroids or immunotherapy are critical to preserve the organ.
During conditioning therapy prior to hematopoietic stem cell transplant, which nursing intervention has the highest priority?
A. Encourage fluid intake to promote diuresis.
B. Implement strict infection precautions and monitor for pancytopenia.
C. Provide high-protein meals to maintain nutrition.
D. Administer antipyretics around the clock.
B. Implement strict infection precautions and monitor for pancytopenia.
Rationale: Conditioning causes myeloablation, resulting in severe pancytopenia and immunosuppression. Neutropenic precautions, hand hygiene, and daily lab monitoring are vital to prevent life-threatening infection.
Which action is most important for a nurse caring for a patient in the first week after a combined kidney and bone marrow transplant?
A. Strict hand hygiene and protective isolation
B. Encourage early ambulation to prevent DVT
C. Provide a high-protein, high-calorie diet
D. Monitor for depression and withdrawal
A. Strict hand hygiene and protective isolation
Rationale: Both solid organ and HSCT recipients are profoundly immunocompromised from conditioning therapy and immunosuppressants. Infection prevention through isolation and meticulous hand hygiene is the top nursing priority.
A nurse caring for a patient with disseminated intravascular coagulation (DIC) notes oozing from IV sites and petechiae. Which lab finding supports this diagnosis?
A. ↑ Platelets, ↓ D-dimer
B. ↑ Fibrinogen, normal PT/PTT
C. ↓ Platelets, ↑ PT/PTT, ↑ D-dimer
D. Normal coagulation panel
C. ↓ Platelets, ↑ PT/PTT, ↑ D-dimer
Rationale: DIC causes consumption of clotting factors and platelets, prolonging PT/PTT and raising D-dimer (indicating fibrinolysis). Fibrinogen and platelets drop due to overuse in widespread clotting.
A nurse suspects shaken baby syndrome in a 4-month-old with seizures and retinal hemorrhages. What is the nurse’s priority action?
A. Confront the caregiver about suspected abuse.
B. Provide comfort measures and document all findings objectively.
C. Delay reporting until more evidence is gathered.
D. Notify the provider only if the parents admit to shaking.
B. Provide comfort measures and document all findings objectively.
Rationale: The nurse must focus on the infant’s safety, document objectively, and report suspicion to child protective services per mandatory reporting laws. Confrontation is inappropriate and may endanger the child further.
A patient on tacrolimus and mycophenolate reports malaise and fever. Which nursing instruction is most important?
A. “These are normal side effects; continue your medications.”
B. “Take an extra dose of tacrolimus if you feel unwell.”
C. “Contact your transplant provider immediately.”
D. “Stop your antimetabolite drug until your fever resolves.”
C. “Contact your transplant provider immediately.”
Rationale: Immunosuppressants increase infection risk, and even low-grade fevers may indicate serious infection or rejection. Patients must never alter doses independently and should seek immediate medical evaluation.
On post-transplant day 20, a patient develops a pruritic rash on the palms and diarrhea. Which complication does the nurse suspect?
A. Graft rejection
B. Graft-versus-host disease (GVHD)
C. Veno-occlusive disease (VOD)
D. Serum sickness
B. Graft-versus-host disease (GVHD).
Rationale: Acute GVHD typically appears within 30 days post-transplant and affects skin, GI tract, and liver. Early manifestations include rash, diarrhea, and elevated LFTs. Treated with immunosuppressants (tacrolimus, cyclosporine, methotrexate).
A nurse caring for a hematopoietic stem cell transplant patient notes jaundice, hepatomegaly, and rapid weight gain. Which complication should the nurse suspect?
A. Acute GVHD
B. Veno-occlusive disease (VOD)
C. Acute rejection
D. Hemolytic anemia
B. Veno-occlusive disease (VOD)
Rationale: VOD (hepatic sinusoidal obstruction syndrome) occurs after high-dose chemotherapy or HSCT. Signs include jaundice, hepatomegaly, ascites, and sudden weight gain due to hepatic venous congestion. Supportive care and close monitoring are essential.
A patient with idiopathic thrombocytopenic purpura (ITP) has platelet count 22,000/µL. Which nursing intervention is most appropriate?
A. Administer IM vitamin K injection.
B. Apply sequential compression devices.
C. Use a soft toothbrush and avoid invasive procedures.
D. Encourage vigorous activity to maintain circulation.
C. Use a soft toothbrush and avoid invasive procedures.
Rationale: Patients with platelet counts <50,000/µL are at high risk for bleeding. Implement bleeding precautions—avoid IM injections, hard bristle toothbrushes, and trauma.
A toddler is pulled from a backyard pool and is now breathing spontaneously but lethargic. Which nursing action is most important during initial care?
A. Keep the child warm and monitor for respiratory distress.
B. Give oral fluids to prevent dehydration.
C. Place the child in the Trendelenburg position.
D. Discourage parental presence during assessment.
A. Keep the child warm and monitor for respiratory distress.
Rationale: Near-drowning victims are at risk for delayed pulmonary edema and hypothermia. Continuous monitoring of airway, breathing, and oxygen saturation is crucial, along with temperature stabilization and emotional support for the family.
The nurse is educating a liver transplant recipient on immunosuppressive therapy. Which statement indicates the need for further teaching?
A. “I’ll take my medications at the same time every day.”
B. “I’ll avoid grapefruit and live vaccines.”
C. “If I miss a dose, I’ll take it as soon as I remember.”
D. “I can stop my medications once my liver tests are normal.”
D. “I can stop my medications once my liver tests are normal.”
Rationale: Immunosuppressive therapy is lifelong. Stopping or skipping doses leads to acute rejection and graft failure. Teaching emphasizes adherence, infection prevention, and monitoring for toxicity.
The nurse is providing discharge education for a patient following allogenic HSCT. Which statement by the patient indicates a need for further teaching?
A. “I’ll wear a mask and avoid crowds for at least three months.”
B. “I can stop my prophylactic antivirals once I feel better.”
C. “I’ll call the clinic right away if I develop a fever or rash.”
D. “I’ll use hand hygiene and avoid raw or undercooked foods.”
B. “I can stop my prophylactic antivirals once I feel better.”
Rationale: Patients remain immunocompromised for months to years after transplant. Antivirals, antifungals, and antibacterials are continued as prescribed — stopping early greatly increases infection risk.
The nurse provides discharge teaching for a kidney transplant recipient who also received stem cell therapy. Which statement by the patient indicates correct understanding?
A. “I will stop wearing my mask once my white blood cell count normalizes.”
B. “I’ll avoid live vaccines and report any fever immediately.”
C. “If I feel tired, I’ll double my steroid dose that day.”
D. “I only need to take my immunosuppressants until the new kidney adjusts.”
B. “I’ll avoid live vaccines and report any fever immediately.”
Rationale: Post-transplant patients remain immunosuppressed long-term, increasing infection risk. Live vaccines are contraindicated, and even low-grade fevers require prompt evaluation for infection or rejection.