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Medications

100

What does aspirin do?

Decreases Platelet Aggregation

200

The nurse is assessing a client whose warfarin (Coumadin) therapy was discontinued 3 weeks ago. Which laboratory test result indicates that the client’s warfarin therapy is no longer therapeutic? a. International normalized ratio (INR), 0.9 b. Reticulocyte count, 1% c. Serum ferritin level, 350 ng/mL d. Total white blood cell (WBC) count, 9000/mm3

A Warfarin therapy increases the INR. Normal INR ranges between 0.7 and 1.8. Therapeutic warfarin levels, depending on the indication of the disorder, should maintain the INR between 1.5 and 3.0. When the effects of warfarin are no longer present, the INR returns to normal levels. Warfarin therapy does not affect white blood cell count, serum ferritin level, or reticulocyte count.

300

The nurse is caring for a client who is receiving heparin therapy. How does the nurse evaluate the therapeutic effect of the therapy? a. Evaluate platelets. b. Monitor the partial thromboplastin time (PTT). c. Assess bleeding time. d. Monitor fibrin degradation products.

B The PTT assesses the intrinsic clotting cascade. Heparin therapy is monitored by the PTT. Platelets are monitored by the platelet count laboratory value, bleeding time evaluates vascular and platelet activity during hemostasis, and fibrin degradation products help assess for fibrinolysis.

400

The nurse is teaching a client who is receiving warfarin (Coumadin). Which topics does the nurse include in the teaching plan? (Select all that apply.) a. Foods high in vitamin K b. Using acetaminophen (Tylenol) for minor pain c. Daily exercise and weight management d. Use of a safety razor and soft toothbrush e. Blood testing regimen

A, B, D,E The client on warfarin will need to know which foods are high in vitamin K because vitamin K intake must be consistent to avoid interfering with the anticoagulant properties of warfarin. Clients should not take aspirin or NSAIDs for minor pain owing to their anticoagulant properties. Clients must use safety razors and soft toothbrushes to avoid bleeding episodes. The client on warfarin needs regular blood tests for prothrombin time (PT) and international normalized ratio (INR). Daily exercise and weight management are not specifically important to this client.

500

The nurse is administering a prescribed fibrinolytic to a client who is having a myocardial infarction (MI). Which adverse effect does the nurse monitor for? a. Bleeding b. Orthostatic hypotension c. Deep vein thrombosis d. Nausea and vomiting

A A fibrinolytic lyses any clots in the body, thus causing an increased risk for bleeding. Fibrinolytic therapy does not place the client at risk for hypotension, thrombosis, or nausea and vomiting.

Labs

100

The nurse is performing an admission assessment on a 46-year-old client, who states, “I have been drinking a 12-pack of beer every day for the past 20 years.” Which laboratory abnormality does the nurse correlate with this history? a. Decreased white blood cell (WBC) count b. Decreased bleeding time c. Elevated prothrombin time (PT) d. Elevated red blood cell (RBC) count

C The liver is the site for production of prothrombin and most of the blood-clotting factors. If the liver is damaged because of chronic alcoholism, it is unable to produce these clotting factors. Therefore, the PT could become elevated, which would reflect deficiency of some clotting factors. The WBC would not be elevated in this situation because no infection is present. Bleeding time would likely increase. The client’s RBC count most likely would not be affected unless the client was bleeding, in which case it would decrease.

200

The nurse is assessing the following laboratory results of a client before discharge. Which instruction does the nurse include in this client’s discharge teaching plan? Hemoglobin 15 g/dL Hematocrit 45% White blood cell (WBC) count 2000/mm3 Platelet count 250,000/mm3 a. “Avoid contact sports.” b. “Do not take any aspirin.” c. “Eat a diet high in iron.” d. “Perform good hand hygiene.

D A normal WBC count is 5000 to 10,000/mm3. A white blood cell count of 2000/mm3 is low and makes this client at risk for infection. Good handwashing technique is the best way to prevent the transmission of infection. The other laboratory results are all within normal limits.

300

A patient with non-Hodgkin’s lymphoma develops a platelet count of 18,000/µl during chemotherapy. An appropriate nursing intervention for the patient based on this finding is to a. provide oral hygiene every 2 hours. b. check all stools for occult blood. c. check the temperature every 4 hours. d. encourage fluids to 3000 mL/day.

B Because the patient 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.

400

What does PT and PTT measure?

PT- prothrombin time- measures how long takes blood to clot (11-12.5 seconds) Warfarin therapy monitored with this value. INR (international normalized ratio) stands for a way of standardizing the results of prothrombin time tests. Another blood clotting test, called partial thromboplastin time (PTT), measures other clotting factors. Partial thromboplastin time and prothrombin time are often done at the same time to check for bleeding problems or the chance for too much bleeding in surgery.

500

What is the importance of hemoglobin?

Transport and delivery of oxygen to tissues.

What am I

100

Abnormally low levels of healthy red blood cells or hemoglobin Labs may show decrease in RBC or H/H Weakness, fatigue, and a run-down feeling Tires easily, is often out of breath, and feels faint or dizzy

Anemia

200

Arise in a lymph node and then spread to neighbor lymph nodes and then eventually to other organs- A bully! You may find an enlarged node (most common finding), weight loss, fatigue, weakness, fever, night sweats. malignant condition with proliferation of abnormal giant cells called Reed-Sternberg cells which are located in the lymph nodes.

Hodgkins Lymphoma

300

Abnormally low number of platelets in the bloodstream (platelet number drops below 150,000) Easily bruise and can have episodes of excess bleeding (a hemorrhage/occult bleeding). Can be from following three processes: decreased platelet production by the bone marrow ; increased trapping of platelets by an enlarged spleen; or a more rapid than normal destruction of platelets from various processes.

Thrombocytopenia Can result in fatal bleeding, but can indicate various other, more serious, cancers and disorders that affect the blood cells. Requires a thorough medical evaluation. There is no known way to prevent, but can improve when underlying cause treated.

400

All lymphoid cancers that do not have Reed-Sternberg cell Do not spread in lymphatic system in orderly fashion Painless swelling of cervical, axillary, inguinal, and femoral nodes most often seen Group of diseases and must be classified using WHO system

Non-Hodgkin's Lymphoma

500

Uncontrolled production of immature WBC’s (blasts) that cannot provide infection protection May be acute or chronic W/O treatment patient dies from infection or hemorrhage from reduced platelet function

Leukemia AML- most common adult onset ALL- most common in children CML- 20% of adults, mostly greater than 50 years CLL- most common chronic leukemia and mostly in greater than 50 years old Infection Protection is a major focus Hematopoietic Stem Cell Transplant- eradicates patients hematopoietic stem cells and replaces them with a donor

Nursing Care

100

The nurse is assessing a client with liver failure. Which assessment is the highest priority for this client? a. Auscultation for bowel sounds b. Assessing for deep vein thrombosis c. Monitoring of blood pressure hourly d. Assessing for signs of bleeding

D. All these options are important in assessment of the client, but the most important action is assessment for signs of bleeding. The liver is the site of production of prothrombin and most of the blood-clotting factors. Clients with liver failure run a high risk of having problems with bleeding.

200

The nurse is assessing a client with numerous areas of bruising. Which question does the nurse ask to determine the cause of this finding? a. “Do you take aspirin?” b. “How often do you exercise?” c. “Are you a vegetarian?” d. “How often do you take Tylenol?”

A. Platelet aggregation is essential for blood clotting. An inability to clot blood when an injury occurs can result in bleeding, which would cause bruising. Aspirin is a drug that interferes with platelet aggregation and has the ability to “plug” an extrinsic event, such as trauma. Vitamin K found in green vegetables enhances clotting factors, which would improve the ability to stop bleeding associated with an extrinsic event. Acetaminophen (Tylenol) and exercise do not inhibit clotting factors.

300

The nurse is planning discharge teaching for a client who has a splenectomy. Which statement does the nurse include in this client’s teaching plan? a. “Avoid crowds and people who are sick.” b. “Do not eat raw fruits or vegetables.” c. “Avoid environmental allergens.” d. “Do not play contact sports

A. The spleen is the major site of B-lymphocyte maturation and antibody production. Those who undergo splenectomies for any reason have a decreased antibody-mediated immune response and are particularly susceptible to viral infections. Eating raw fruits and vegetables places the client at risk for bacterial infections. The body responds to environmental allergens with an unspecific inflammatory process. The client is not at risk for bleeding or injury due to contact sports.

400

The nurse is caring for a patient with immune thrombocytopenic purpura (ITP) who has an order for a platelet transfusion. Which patient information indicates that the nurse should consult with the health care provider before administering platelets? a. The platelet count is 42,000/mL. b. Blood pressure (BP) is 94/56 mm Hg. c. Blood is oozing from the venipuncture site. d. Petechiae are present on the chest and back.

A Platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/ml unless the patient 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.

500

The nurse is monitoring a client with liver failure. Which assessments does the nurse perform when monitoring for bleeding in this client? (Select all that apply.) a. Gums b. Lung sounds c. Urine d. Stool e. Hair

A, C, D The liver is the site for production of clotting factors. Without these factors, the client is at risk for bleeding. Common areas of bleeding include the gums and mucous membranes, bladder, and gastrointestinal tract. Lung sounds and hair are part of the assessment but are not essential in the presence of liver failure and hematologic abnormalities.

Clinical Reasoning

100

The nurse is planning care for a client who has a platelet count of 30,000/mm3. Which intervention does the nurse include in this client’s plan of care? a. Oxygen by nasal cannula b. Bleeding Precautions c. Isolation Precautions d. Vital signs every 4 hours

B. The normal platelet count ranges between 150,000 and 400,000/mm3. This client is at extreme risk for bleeding. Although it is necessary to notify the provider, the nurse would first protect the client by instituting Bleeding Precautions. The other interventions are not related to the low platelet count.

200

The nurse is caring for a client who has an elevated white blood cell count. Which intervention does the nurse implement for this client? a. Administer the prescribed Tylenol. b. Hold the client’s prescribed steroids. c. Assess the client’s respiratory rate. d. Obtain the client’s temperature.

D White blood cells provide immunity and protect against invasion and infection. An elevated white blood cell count could indicate an infectious process, which could cause an elevation in body temperature. Tylenol would treat a fever but not the elevated white blood cell count. Steroids place the client at higher risk for infection but should not be stopped suddenly. The respiratory rate does not need to be assessed in this client.

300

The nurse is completing the preoperative checklist on a client. The client states, “I take an aspirin every day for my heart.” How does the nurse respond? a.“I will call your doctor and request a prescription for pain medication.” b.“I need to call the surgeon and reschedule your surgery.” c.“I’ll give you the prescribed Tylenol to minimize any headache before surgery.” d.“I need to administer vitamin K to prevent bleeding during the procedure.”

B Aspirin interferes with platelet aggregation—the first step in the blood-clotting cascade—and decreases the ability of the blood to form a platelet plug. These effects last for longer than 1 week after just one dose of aspirin. The client may need to have the surgery rescheduled. Vitamin K, prescribed pain medication, and Tylenol cannot reduce the anticlotting effects of aspirin.

400

Which of the following assessment data obtained by the nurse when caring for a patient with thrombocytopenia should be immediately communicated to the health care provider? a. The platelet count is 52,000/µl. b. The patient is difficult to arouse. c. There are large bruises on the back. d. There are purpura on the oral mucosa.

B Difficulty in arousing the patient 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 patient with thrombocytopenia.

500

All of these patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? a. 19-year-old with no previous health problems who has a nontender lump in the axilla b. 46-year-old with sickle cell anemia who says “that my eyes always look sort of yellow” c. 21-year-old with hemophilia who wants to learn how to self-administer factor VII replacement d. 50-year-old with early-stage chronic lymphocytic leukemia who has complaints of chronic fatigue

A The patient’s age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently.