Arnad, Ed Robert D.C. Bellotindos, Christine Marie M. Diansuy, Michaella Tisha Marie S. Corral, Mavis Amor N.

. BSN IV-E; NCA 401-E NURSING RESEARCH AND HEMATOLOGY

Purposes of Nursing Research Notes Nursing research is a vital component to the health care field. Nursing research helps implement new changes in the life long care of individuals and is used to develop treatments that provide the most optimum level of care. Nursing research focuses on developing and promoting high levels of standards in the following areas: high quality management of patients during long term illnesses, developing advancements that aid patients in recovery, developing standards that help reduce the numbers of disease in the community, promoting healthy lifestyles and preventing the onset of preventable diseases and illnesses, helping to instill techniques and treatments that increase the quality of life in patients with degenerative diseases, as well as easing the transition for those who are facing the end of life. Nursing research encompasses a holistic approach and views the treatment of the patient, family members, and caregivers as a whole. By developing healing methods that focus on the whole community involved in the patient's care, there is a greater level of effectiveness when new techniques are implemented. By utilizing this holistic approach, quality of care is enhanced and the patient will receive the best care.The health field makes significant advances every day. As science unfolds and expands man's concept of the boundaries of medicine, we can expect that this will cause considerable and important leaps in the area of health and treatments. With Nursing Research, these new changes will continue to be implemented and developed into therapies and treatments that will ultimately bring faster healing and better quality of lifeto the patients who need them most. These therapies are not only for the bettering of the patient, but also for the community as a whole. Scientific progress and discovery means less disease, fewer illnesses, more vaccines, and a better quality of life for the community as a whole. Specific Purposes of Nursing Research Patient Care

Through qualitative assessment of the interactions between medical staff and patients, researchers can profoundly analyze experiences and understand the basis of failings or successes. Quantitative evaluation, on the other hand, accumulates empirical data that are useful in establishing trends and hypothesizing. Both approaches contribute to formulating informative and effective policy and procedure, around patient care. Additionally, research into medical staff's work pressures, schedules and obligations can be used to promote job satisfaction and encourage staff retention. Nursing research is necessary in building a comprehensive theoretical and practical knowledge base. Findings help to contextualize and establish practical approaches to implement theory. It also facilitates theoretical progress by raising questions regarding function, role and responsibility of nursing. Theory is essential in framing nursing practices. In 1

Theory and Knowledge

1937, Virginia Henderson pioneered the concept of patient-centered, holistic care, which continues to inform health care across the world.

Education and Training Nursing research is useful in validating the nature and delivery of medical staff training. Findings on good practice and limitations is a cost-effective approach to developing tailored programs, which enrich health care professionals with skills and the knowledge necessary to offer medical treatment. This also contributes to increased education among patients and families, who often rely on nurses as an essential point of contact. Nursing theory and research has established nursing as an educational field, independent of medicine, opening the door to a variety of professions, such as a nursing researcher.

Purposes of Nursing Research Questions: 1. Kevin is a member of the Nursing Research Council of the hospital. His first assignment is to determine the level of patient satisfaction on the care they received from the hospital. He plans to include all adult patients admitted from April to May, with average length of stay of 3-4 days, first admission, and with no complications. Which of the following is an extraneous variable of the study? A. Date of admission B. Length of stay C. Age of patients D. Absence of complications 2. He thinks of an appropriate theoretical framework. Whose theory addresses the four modes of adaptation? A. Martha Rogers B. Sr. Callista Roy C. Florence Nightingale D. Jean Watson 3. He opts to use a self-report method. Which of the following is NOT TRUE about this method? A. Most direct means of gathering information B. Versatile in terms of content coverage C. Most accurate and valid method of data gathering D. Yields information that would be difficult to gather by another method 4. Which of the following articles would Kevin least consider for his review of literature? A. Story-Telling and Anxiety Reduction Among Pediatric Patients B. Turnaround Time in Emergency Rooms C. Outcome Standards in Tertiary Health Care Institutions D. Environmental Manipulation and Client Outcomes 5. Which of the following variables will he likely EXCLUDE in his study? 2

A. Competence of nurses B. Caring attitude of nurses C. Salary of nurses D. Responsiveness of staff 6. He plans to use a Likert Scale to determine A. degree of agreement and disagreement B. compliance to expected standards C. level of satisfaction D. degree of acceptance 7. He checks if his instruments meet the criteria for evaluation. Which of the following criteria refers to the consistency or the ability to yield the same response upon its repeated administration? A. Validity B. Reliability C. Sensitivity D. Objectivity 8. Which criteria refer to the ability of the instrument to detect fine differences among the subjects being studied? A. Sensitivity B. Reliability C. Validity D. Objectivity 9. Which of the following terms refer to the degree to which an instrument measures what it is supposed to be measure? A. Validity B. Reliability C. Meaningfulness D. Sensitivity 10. He plans for his sampling method. Which sampling method gives equal chance to all units in the population to get picked? A. Random B. Accidental C. Quota D. Judgment ANSWERS AND RATIONALE 3

1. Answer: (C) Age of patients

An extraneous variable is not the primary concern of the researcher but has an effect on the results of the study. Adult patients may be young, middle or late adult.
2. Answer: (B) Sr. Callista Roy

Sr. Callista Roy developed the Adaptation Model which involves the physiologic mode, self-concept mode, role function mode and dependence mode
3. Answer: (C) Most accurate and valid method of data gathering

The most serious disadvantage of this method is accuracy and validity of information gathered
4. Answer: (B) Turnaround Time in Emergency Rooms

The article is for pediatric patients and may not be relevant for adult patients.
5. Answer: (C) Salary of nurses

Salary of staff nurses is not an indicator of patient satisfaction, hence need not be included as a variable in the study.
6. Answer: (A) degree of agreement and disagreement

Likert scale is a 5-point summated scale used to determine the degree of agreement or disagreement of the respondents to a statement in a study.
7. Answer: (B) Reliability

Reliability is repeatability of the instrument; it can elicit the same responses even with varied administration of the instrument
8. Answer: (A) Sensitivity

Sensitivity is an attribute of the instrument that allow the respondents to distinguish differences of the options where to choose from
9. Answer: (A) Validity

Validity is ensuring that the instrument contains appropriate questions about the research topic
10. Answer: (A) Random

Random sampling gives equal chance for all the elements in the population to be picked as part of the sample.

Overview:

HEMATOLOGICAL SYSTEMS

I Blood II Blood vessels III Blood forming organs 1. Thymus removed myasthenia gravis 2. Liver largest gland 3. Lymph nodes

4. 5.

6.

Lymphoid organs payers patch Bone marrow Spleen destroys RBC

Blood vessels 1. Veins SVC, IVC, Jugular vein blood towards the heart 2. Artery carries blood away from the 1. Aorta, carotid 3. Capillaries Blood 45% formed elements 55% plasma fluid portion of vlood. Yellow color. Serum Plasma CHONs (Produced in Liver) 1. Albumin- largest, most abundant plasma Maintains osmotic pressure preventing edema FXN: promotes skin integrity 2. Globulins alpha transports steroids Hormones & bilirubin - Transports iron & copper Gamma transport immunoglobulins or antibodies 3. Prothrombin fibrinogen clotting factor to prevent bleeding

Formed Elements: 1. RBC (erythrocytes) Spleen life span = 120 days (N) 3 6 M/mm3 - Anucleated - Biconcave discs - Has molecules of Hgb (red cell pigment) Transports & carries O2

SICKLE CELL ANEMIA sickle shaped RBC. Should be round. Impaired circulation of RBC. -immature cells=hemolysis of RBC=decreased hgb
3 Nsg priority 1. a/w avoid deoxygenating activities - High altitude is bad 2. Fluid deficit promote hydration 3. Pain & comfort Hgb ( hemoglobin) F= 12 14 gms % M = 14-16 gms % Hct 3x hgb 12 x 3 = 36 (hamatocrit) F 36 42% 14 x 3 = 42 M 42 48% Average 42% - Red cell percentage in whole red Substances needed for maturation of RBC a.) Folic acid b.) Iron c.) Vit C d.) Vit B12 (cyanocobalamin) e.) Vit B6 (Pyridoxine) f.) Intrinsic factor Pregnant: 1st trimester- Folic acid prevent neural tube deficit 3rd tri iron Life span of rbc 80 120 days. Destroyed at spleen.

WBC leucocytes 5,000 10,000/mm3 GRANULOCYTES 1. Polymorphonuclearneutrophils Most abundant 60-70% WBC - fx short term phagocytosis For acute inflammation 2. PM Basophils -Involved in Parasitic infection - Release of chem. Mediator for inflammation Serotonin, histamine, prostaglandin, bradykinins 3. PM eosinophils - Allergic reactions

NON-GRANULOCYTES 1. Monocytes (macrophage) - largest WBC - involved in long term phagocytes - For chronic inflammation - Other name macrophage Macrophage in CNS- microglia Macrophage in skin Histiocytes Macrophage in lungs alveolar macrophage Macrophage in Kidneys Kupffer cells 2. Lymphocytes B Cell L bone marrow or bursa dependent T cell devt of immunity- target site for HIV NK cell natural killer cell Have both antiviral & anti-tumor properties 3.Platelets (thrombocytes) N- 150,000 450, 000/ mm3 it promotes hemostasis prevention of blood loss by activating clotting - Consists of immature or baby platelets known as megakaryocytes target of virus dengue - Normal lifespan 9 12 days

Drug of choice for HIV Zidovudine (AZT or Retrovir) Standard precaution for HIV gloves, gown, goggles & mask Malaria night biting mosquito Dengue day biting mosquito Signs of platelet dis function: a.) Petecchiae b.) Ecchemosis/ bruises c.) Oozing or blood from venipuncture site

ANEMIA
Iron deficiency Anemia chronic normocytic, hypocromic (pale), microcytic anemia due to inadequate absorption of iron leading to hypoxemic injury. Incidence rate: 1. Common developed country due to high cereal intake Due to accidents common on adults 2. Common tropical countries blood sucking parasites 3. Women 15 35yo reproductive yrs 4. Common among the poor poor nutritional intake Suicide - common in teenager Poisoning common in children (aspirin) Aspiration common in infant Accidents common in adults Choking common in toddler SIDS common in infant in US 2. Common in tropical zone Phil due blood sucks Predisposing factor: 1. Chronic blood loss a. Trauma

b. Mens c. GIT bleeding: i. Hematemesisii. Melena upper GIT duodenal cancer iii. Hematochezia lower GIT large intestine fresh blood from rectum 2. Inadequate intake of food rich in iron 3. Inadequate absorption of iron due to : a. Chronic diarrhea b. Malabsorption syndrome celiac disease-gluten free diet. Food for celiac pts- sardines c. High cereal intake with low animal CHON ingestion d. Subtotal gastrectomy 4. Improper cooking of food S/Sx: 1. 2. 3. 4. 5. Asymptomatic Headache, dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor Brittle hair, spoon shaped nails (KOILONYCHIA)=Dec O2=hypoxia=atrophy of epidermal cells Atropic glossitis, dysphagia, stomatitis Pica abnormal craving for non edible food (caused by hypoxia=dec tissue perfusion=psychotic behavior)

Brittle hair, spoon shaped nail atrophy of epidermal cells N = capillary refill time < 2 secs N = shape nails biconcave shape, 180 Atrophy of cells Plummer Vinsons Syndrome due to cerebral hypoxia 1. Atropic glossiti inflammation of tongue due to atrophy of pharyngeal and tongue cells 2. Stomatitis mouth sores 3. Dysphagia Dx Proc: 1. RBC 2. Hgb 3. Reticulocyte 4. Hct 5. Iron 6. Ferritin Nsg Mgt 1. Monitor signs of bleeding of all hema test including urine & stool 2. Complete bed rest dont overtire pt =weakness and fatigue=activity intolerance 3. Encourage iron rich food 3. Raisins, legumes, egg yolk 4. Instruct the pt to avoid taking tea - impairs iron absorption 5. Administer meds a.) Oral iron preparation Ferrous SO4 Fe gluconate Fe Fumarate Nsg Mgt oral iron meds: 1. Administer with meals to lessen GIT irritation 2. If diluting in iron liquid prep adm with straw Straw 1. 2. 3. 4. Lugols Tetracycline Oral iron Macrodantine

3. Give Orange juice for iron absorption

4. Monitor & inform pts S/E

a. b. c. d. e.

Anorexia n/v Abdominal pain Diarrhea or constipation Melena

If pt cant tolerate oral iron prep administer parenteral iron prep example: 1. Iron dextran (IV, IM) 2. Sorbitex (IM) Nsg Mgt parenteral iron prep 1. Administer of use Z tract method to prevent discomfort, discoloration leakage to tissues. 2. Dont massage injection site. Ambulate to facilitate absorption. 3. Monitor S/E: a.) Pain at injury site b.) Localized abscess (nana) c.) Lymphadenopathy d.) Fever/ chills e.) Urticaria itchiness f.) Hypotension anaphylactic shock Anaphylactic shock give epinephrine

PERNICIOUS ANEMIA - megaloblastic, chronic anemia due to deficiency of intrinsic factor leading to
Hypochlorhydria decrease Hcl acid secretion. Lifetime B12 injections. With CNS involvement. Predisposing factor 1. Subtotal gastrectomy removal stomach 2. Hereditary 3. Infl dse of ileum 4. Autoimmune 5. Strict vegetable diet STOMACH Parietal or ergentaffen Oxyntic cells Fxn produce intrinsic factor For reabsorption of B12 For maturation of RBC Diet high caloric or CHO to correct wt loss S/Sx: 1. 2. Headache dizziness, dyspnea, palpitations, cold sensitivity, gen body malaise, pallor GIT changes a. Red beefy tongue PATHOGNOMONIC mouth sores b. Dyspepsia indigestion c. Wt loss d. Jaundice 3. CNS Most dangerous anemia: pernicious due to neuroglogic involvement. a. Tingling sensation b. Paresthesia c. (+) Rombergs test Ataxia Fxn secrets Hcl acid Fx aids in digestion

d. Psychosis Dx:- Shillings test Nsg Mgt Pernicious anemia 1. Enforce CBR 2. Administer B12 injections at monthly intervals for lifetime as ordered. IM- dorsogluteal or ventrogluteal. Not given oral due pt might have tolerance to drug 3. Diet high calorie or CHO. Increase CHON, iron & Vit C 4. Avoid irritating mouthwashes. Use of soft bristled toothbrush is encouraged. 5. Avoid applying electric heating pads can lead to burns

APLASTIC ANEMIA stem cell disorder due to bone marrow depression leading to pancytopenia all RBC are decreased
Decrease RBC Anemia Increase WBC leukocytocys Increase RBC polycythemia vera complication stroke, CVA, thrombosis Predisposing factors leading to Aplastic Anemia 1. Chemicals Banzene & its derivatives 2. radiation 3. Immunologic injury 4. Drugs cause bone marrow depression a. Broad spectrum antibiotic - Chlorampenicol - Sulfonamides bactrim b. Chemo therapeutic agents Methotrexate alkylating agents Nitrogen mustard anti metabolic Vincristine plant alkaloid S/Sx: 1. Anemia: a. Weakness & fatigue b. Headache, dizziness, dyspnea c. cold sensitivity, pallor d. palpitations 2. Leucopenia increase susceptibility to infection 3. Thrombocytopenia Peticchiae Oozing ofblood from venipuncture site ecchymosis Dx: 1. CBC pancytopenia 2. Bone marrow biopsy/ aspiration at post iliac crest reveals fatty streaks in bone marrow Nsg Mgt: 1. Removal of underlying cause 2. Blood transfusion as ordered 3. Complete bed rest 4. O2 inhalation 5. Reverse isolation due leukopenia 6. Monitor signs of infection 7. Avoid SQ, IM or any venipuncture site = HEPLOCK 8. Use electric razor when shaving to prevent bleeding 9. Administer meds Immunosuppresants Anti lymphocyte globulin (Alg) given via central venous catheter, 6 days 3 weeks to achieve max therapeutic effect of drug. decrease WBC leukopenia decrease platelets thrombocytopenia

BLOOD TRANSFUSION: Objectives: 1. To replace circulating blood volume 2. To increase O2 carrying capacity of blood 3. To combat infection if theres decrease WBC 4. To prevent bleeding if theres platelet deficiency Nsg Mgt & principles in Blood Transfusion 1. Proper refrigeration 2. Proper typing & crossmatching Type O universal donor AB universal recipient 85% of people is RH (+) 3. Asceptically assemble all materials needed: a.) Filter set b.) Isotonic or PNSS or .9NaCl to prevent Hemolysis Hypotonic sol swell or burst Hypertonic sol will shrink or crenate c.) Needle gauge 18 - 19 or large bore needle to prevent hemolysis. d.) Instruct another RN to recheck the following . Pts name, blood typing & cross typing expiration date, serial number. e.) Check blood unit for presence of bubbles, cloudiness, dark in color & sediments indicates bacterial contamination. Dont dispose. Return to blood bank. f.) Never warm blood products may destroy vital factors in blood. - Warming is done if with warming device only in EMERGENCY! For multiple BT. - Within 30 mins room temp only! g.) Blood transfusion should be completed < 4hrs because blood that is exposed at room temp for > 2h causes blood deterioration. h.) Avoid mixing or administering drug at BT line leads to hemolysis i.) Regulate BT 10 15 gtts/min KVO or 100cc/hr to prevent circulatory overload j.) Monitor VS before, during & after BT especially q15 mins(local board) for 1st hour. NCLEX-q5min for 1st 15min. - Majority of BT reaction occurs within 1h.

BT reactions S/Sx Hemolytic reaction: H hemolytic Reaction 1. Headache, dizziness, dyspnea, palpitation, lumbar/ sterna/ flank pain, A allergic Reaction hypotension, flushed skin , (red) port wine urine. P pyrogenic Reaction C circulatory overload A air embolism T - thrombocytopenia C citrate intoxication expired blood =hyperkalemia H hyperkalemia Nsg Mgt: Hemolytic Reaction: 1. Stop BT 2. Notify Doc 3. Flush with plain NSS 4. Administer isotonic fluid sol to prevent acute tubular necrosis & conteract shock 5. Send blood unit to blood bank for reexamination 6. Obtain urine & blood samples of pt & send to lab for reexamination 7. Monitor VS & Allergic Rxn

Allergic Reaction:
S/Sx 1. Fever/ chills

10

2. 3. 4. 5.

Urticaria/ pruritus Dyspnea Laryngospasm/ bronchospasm Bronchial wheezing

Nsg Mgt: 1. Stop BT 2. Notify Doc 3. Flush with PNSS 4. Administer antihistamine diphenhydramine Hcl (Benadryl). Give bedtime.SE-Adult-drowsiness. Child-hyperactive If (+) Hypotension anaphylactic shock administer epinephrine 5. Send blood unit to blood bank 6. Obtain urine & blood samples send to lab 7. Monitor VS & IO 8. Adm. Antihistamine as ordered for AllergicRxn, if (+) to hypotension indicates anaphylactic shock 4. administer epinephrine 9. Adm antipyretic & antibiotic for pyrogenic Rxn & TSB

Pyrogenic Reaction:
S/Sx

a.) Fever/ chills b.) Headache c.) Dyspnea

Nsg Mgt: 1. 2. 3. 4. 5. 6. 7.

d. tachycardia e. palpitations f. diaphoresis

8.
Sx a. b. c. d.

Stop BT Notify Doc Flush with PNSS Administer antipyretics, antibiotics Send blood unit to blood bank Obtain urine & blood samples send to lab Monitor VS & IO Tepid sponge bath offer hypothermic blanket

Circulatory Overload:
Dyspnea Orthopnea Rales or crackles Exertional discomfort

Nsg Mgt: 1. Stop BT 2. Notify Doc. Dont flush due pt has circulatory overload. 3. Administer diuretics Priority cases: Hemolytic Rxn 1st due to hypotension 1st priority attend to destruction of Hgb O2 brain damage Allergic 3rd Pyrogenic 4th Circulatory 2nd Hemolytic Anaphylitic 2nd 1st priority

DIC DISSEMINATED INTRAVASCULAR COAGULATION

5. Acute hemorrhagic syndrome char by wide spread bleeding & thrombosis due to a def of clotting factors (Prothrombin &
Fibrinogen).

11

Predisposing factor: 1. Rapid BT 2. Massive trauma 3. Massive burns 4. Septicemia 5. Hemolytic reaction 6. Anaphylaxis 7. Neoplasia growth of new tissue 8. Pregnancy S/Sx 1. 2. 3. 4. 5. Petechiae widespread & systemic (lungs, lower & upper trunk) Ecchymosis widespread Oozing of blood from venipunctured site Hemoptysis cough blood Hemorrhage Oliguria late sx

6.

Dx Proc 1. CBC reveals decrease platelets 2. Stool for occult blood (+) Specimen stool 3. Opthalmoscopic exam sub retinal hemorrhage 4. ABG analysis metabolic acidosis pH pH ph ph ph HCO3 PCO2 PCO2 HCO3 HCO3

R O M E

respiratory alkalosis respiratory acidosis metabolic alkalosis metabolic acidosis

Diarrhea met acidosis Vomitting met alk Pyloric stenosis met alkalosis vomiting Ileostomy or intestinal tubing met acidosis Cushings met alk DM met acid Chronic bronchitis resp acid with hypoxemia, cyanosis Nsg Mgt DIC 1. Monitor signs of bleeding hema test + urine, stool, GIT 2. Administer isotonic fluid solution to prevent shock. 3. Administer O2 inhalation 4. Administer meds a. Vit K aquamephyton b. Pitressin or vasopressin to conserve water. 5. NGT lavage - Use iced saline lavage 6. Monitor NGT output 7. Provide heplock 8. Prevent complication: hypovolemic shock Late signs of hypovolemic shock : anuria

Hematology Questions 12

1. Ms. X is diagnosed with acquired immunodeficiency syndrome (AIDS). The nurse caring for this patient is aware that for a patient to be diagnosed with HIV she should have which condition? a. Infection of HIV, have a CD4+ T-cell count of 500 cells/microliter, history of acute HIV infection b. Infection with Tuberculosis, HIV and cytomegalovirus c. Infection of HIV, have a CD4+ T-cell count of >200 cells/microliter, history of acute HIV infection d. Infection with HIV, history of HIV infection and T-cell count below 200 cells/microliter 2. a. b. c. d. The nurse observes precaution in caring for Mr. X as HIV is most easily transmitted in: Vaginal secretions and urine Breast milk and tears Feces and saliva Blood and semen

3. Nurse Jaja is giving an injection to Ms. X. After giving an injection, the nurse accidentally stuck her finger with the needle when the client became very agitated. To determine if the nurse became infected with HIV when is the best time to test her for HIV antibodies? a. Immediately and repeat the test after 12 weeks b. Immediately and repeat the test after 4 weeks c. After a week and repeat the test in 4 months d. After a weeks and repeat the test in 6 months 4. a. b. c. d. 5. a. b. c. d. 6. a. b. c. d. 7. a. b. c. d. 8. a. b. c. d. The blood test first used to identify a response to HIV infection is: Western blot ELISA test CD4+ T-cell count CBC What is the main reason why it is difficult to develop a vaccine against HIV? HIV is still unknown to human HIV mutates easily HIV spreads rapidly throughout the body HIV matures easily Human Immunodeficiency virus belongs to which classifications? Rhabdovirus Rhinovirus Retrovirus Rotavirus Which organ is responsible for stimulating the production of red blood cells? Yellow marrow Red marrow Spleen Kidney In anemia, which of the following blood components is decreased? Erythrocytes Granulocytes Leukocytes Platelets 13

9. a. b. c. d.

The precursor of red blood cells is called: T cells B cells Stem cells Macrophage

10. In erythropoiesis, the sequence of erythrocyte formation is chronologically described in which option? a. Stem cells, erythroblast, reticulocyte, erythrocytes b. Stem cells, reticulocyte, erythroblast, erythrocytes c. Erythroblast, stem cells, reticulocyte, erythrocytes d. Erythroblast, reticulocyte, stem cells, erythrocytes 11. a. b. c. d. Which of the following is true of red blood cell? It is nucleated. It has a lifespan of 100 days Its production and formation depends on the action of the kidney It is produced in the yellow marrow

12. Which type of immunoglobulin passes or crosses the placenta starting at the first trimester of pregnancy? a. IgG b. IgA c. IgM d. All of these 13. The first immunoglobulin produced by the body when the neonate is distressed, has acquired an infection or is challenged is: a. IgG b. IgA c. IgM d. All of these 14. a. b. c. d. 15. a. b. c. d. 16. a. b. c. d. Which of the following is essential for the hemoglobin synthesis during RBC production? Folic Acid Iron Vitamin B12 All of these The age group most at risk for developing anemia is: 20-25 years old 26-32 years old 40-50 years old >65 years old Decreased number of platelets is called: Thrombectomy Thrombocytopenia Thrombocytopathy Thrombocytosis 14

17. To improve the platelet count of a patient with an idiopathic thrombocytopenic purpura, this medication should be given: a. Vitamin K b. Methotrexate c. Corticosteroid d. Acetylsalicylic Acid 18. a. b. c. d. 19. a. b. c. d. B-cells are involved in which of the following types of immunity? Humoral immunity Cell-mediated immunity Antigen-mediated immunity All of these What is the life span of normal platelets? 3-4 months 1-2 months 1-3 days 7-10 days

20. A patient is diagnosed with a systematic lupus erythematous (SLE). SLE primarily attacks which tissues? a. Heart b. Lung c. Nerve d. Connective 21. a. b. c. d. 22. a. b. c. d. 23. a. b. c. d. 24. a. b. c. d. A sign of neurologic involvement in SLE is manifested by: CVA Infection Psychosis Facial tic A classic sign of SLE is: Rashes over the cheeks and nose Weight loss Vomiting Difficulty urinating A laboratory test result that supports the diagnosis of SLE is: Leukocytosis, elevated BUN and CREA Pancytopenia, elevated antinuclear antibody (ANA) titer Thrombocytosis, elevated ESR None of these Which food should a client with leukemia avoid? Wheat bread Steak Orange All of these

15

25. a. b. c. d.

The average length of time from HIV infection to the development of AIDS is? Less than 3 years 5-7 years 10 years More than 10 years

26. You are reviewing the complete blood count (CBC) for a client who has been admitted for knee arthroscopy. Which value is most important to report to the physician prior to surgery? a. White blood cell count 16,000/mm3 b. Hematocrit 33% c. Platelet count 426,000/ mm3 d. Hemoglobin 10.9 g/dL 27. A new RN is preparing to administer packed red blood cells (PRBCs) to a client whose anemia was caused by blood loss after surgery. Which action by the new RN requires that you, as charge nurse, intervene immediately? a. The new RN waits 20 minutes after obtaining the PRBCs before starting the infusion. b. The new RN starts an intravenous line for the transfusion using a 22-gauge catheter. c. The new RN primes the transfusion set using 5% dextrose in lactated Ringers solution. d. The new RN tells the client that the PRBCs may cause a serious transfusion reaction. 28. A 32-year-old client with a history of sickle cell anemia is admitted to the hospital during a sickle cell crisis. The physician orders all of these interventions. Which order will you implement first? a. Give morphine sulfate 4-8 mg IV every hour as needed. b. Start a large-gauge IV line and infuse normal saline at 200 mL/hour. c. Immunize with Pneumovax and Haemophilus influenzae vaccines. d. Administer oxygen at an F102 of 100% per non-rebreather mask. 29. A 78-year-old client admitted to the hospital with chronic anemia caused by possible gastrointestinal bleeding has all of these activities included in the care plan. Which activity is best delegated to an experienced nursing assistant (NA)? a. Use Hemoccult slides to obtain stool specimens. b. Have the client sign a colonoscopy consent form. c. Administer PEG-ES (GoLYTELY) bowel preparation. d. Check for allergies to contrast dye or shellfish. 30. As charge nurse, you are making the daily assignments on the medical-surgical unit. Which client is best assigned to a nurse who has floated from the post-anesthesia care unit (PACU)? a. A 30-year-old client with thalassemia major who has an order for subcutaneous infusion of deferoxamine (Desferal) b. A 43-year-old client with multiple myeloma who needs discharge teaching c. A 52-year-old client with chronic gastrointestinal bleeding who has returned to the unit after a colonoscopy d. A 65-year-old client with pernicious anemia who has just been admitted to the unit 31. You are making a room assignment for a newly arrived client whose laboratory testing indicates pancytopenia. All of these clients are already on the nursing unit. Which one will be the best roommate for the new client? a. The client with digoxin toxicity b. The client with viral pneumonia 16

c. The client with shingles d. The client with cellulitis 32. A client admitted to the hospital with a sickle cell crisis complains of severe abdominal, hip, and knee pain. You observe an LPN accomplishing these client care tasks. Which one requires that you, as charge nurse, intervene immediately? a. The LPN encourages the client to use the ordered PCA. b. The LPN positions cold packs on the clients knees. c. The LPN places a No Visitors sign on the clients door. d. The LPN checks the clients temperature every 2 hours. 33. A 67-year-old client who is receiving chemotherapy for lung cancer is admitted to the hospital with thrombocytopenia. While you are taking the admission history, the client makes these statements. Which statement is of most concern? a. Ive noticed that I bruise more easily since the chemotherapy started. b. My bowel movements are soft and dark brown in color. c. I take one aspirin every morning because of my history of angina. d. My appetite has decreased since the chemotherapy strated. 34. Following a car accident, a client with a Medic-Alert bracelet indicating hemophilia A is admitted to the emergency department (ED). Which physician order should you implement first? a. Transport to radiology for C-spine x-rays. b. Transfuse Factor VII concentrate. c. Type and cross-match for 4 units RBCs. d. Infuse normal saline at 250 mL/hour. 35.As home health nurse, you are taking an admission history for a client who has a deep vein thrombosis and is taking warfarin (Coumadin) 2 mg daily. Which statement by the client is the best indicator that additional teaching about warfarin may be needed? a. I have started to eat more healthy foods like green salads and fruit. b. The doctor said that it is important to avoid becoming constipated. c. Coumadin makes me feel a little nauseated unless I take it with food. d. I will need to have some blood testing done once or twice a week. 36.A client is admitted to the intensive car unit (ICU) with disseminated intravascular coagulation (DIC) associated with a gram-negative infection. Which assessment information has the most immediate implications for the clients care? a. There is no palpable radial or pedal pulse. b. The client complains of chest pain. c. The clients oxygen saturation is 87% d. There is mottling of the hands and feet. 37.A 22-year-old with stage I Hodgkins disease is admitted to the oncology unit for radiation therapy. During the initial assessment, the client tells you, Sometimes I am afraid of dying. Which response is most appropriate at this time? a. Many individuals with this diagnosis have some fears. b. Perhaps you should ask the doctor about medication. c. Tell me a little bit more about your fear of dying. d. Most people with stage I Hodgkins disease survive. 17

38.After receiving change-of-shift report about all of these clients, which one will you assess first? a. A 26-year-old with thalassemia major who has a short-stay admission for a blood transfusion b. A 44-year-old who was admitted 3 days previously with a sickle cell crisis and has orders for a CT scan c. A 50-year-old with newly diagnosed stage IV non-Hodgskins lymphoma who is crying and stating Im not ready to die. d. A 69-year-old with chemotherapy-induced neutropenia who has an elevated oral temperature 39.A long-term-care client with chronic lymphocytic leukemia has a nursing diagnosis of Activity Intolerance related to weakness and anemia. Which of these nursing activities is most appropriate for you, as the charge nurse, to delegate to a nursing assistant? a. Evaluate the clients response to normal activities of daily living. b. Check the clients blood pressure and pulse rate after ambulation. c. Determine which self-care activities the client can do independently. d. Assist the client in choosing a diet that will improve strength. 40.A transfusion of PRBCs has been infusing for 5 minutes when the client becomes flushed and tachypneic and says, I am having chills. Please get me a blanket. Which action should you take first? a. Obtain a warm blanket for the client. b. Check the clients oral temperature. c. Stop the medication. d. Administer oxygen. 1. Answer C. The three criteria for a client to be diagnosed with AIDS are the following: HIV positive CD4+ T-cell count below 200 cells/microliter Have one or more specific conditions that include acute infection of HIV 2. Answer D. Keyword: MOST EASILY. Rationale: HIV is MOST EASILY transmitted in blood, semen and vaginal secretions. However, it has been noted to be found in fecal materials, urine, saliva, tears and breast milk. 3. Answer A. Keyword: BEST TIME. Rationale: To determine if a preexisting infection is present a test should be done immediately and is repeated again in 3 months time (12 weeks) to detect seroconversion as a result of the needle stick. 4. Answer B. Keyword: FIRST. Rationale: The ELISA test is the first screening test for HIV. A Western blot test confirms a positive ELISA test. Other blood tests that support the diagnosis of HIV include CD4+ and CD8 + counts, CBC, immunoglobulin levels, p24 antigen assay, and quantitative ribonucleic acid assays. 5. Answer B. Keyword: MAIN REASON. Rationale: HIV was identified in 1983, thus, A is incorrect. By 1988 two strains of HIV existed, HIV-1 and HIV-2. Viruses spread rapidly and mature easily but these factors dont affect the potential for development against HIV. Mutating too easily makes it hard to create a vaccine against it. 6. Answer C. Rationale: HIV is a retrovirus that has a ribonucleic acid dependent reverse transcriptase.

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7. Answer D. Keyword: STIMULATING THE PRODUCTION OF RBC. Rationale: Kidneys produce and release the hormone erythropoietin that is responsible for initiating the production of RBCs in the red marrow, thus, the correct answer is D. The Red Marrow is the site of RBC production. The spleen is responsible for removing the damage RBC. 8. Answer A. Rationale: Anemia is characterized by a decreased in the number of RBCs. 9. Answer C. Keyword: PRECURSOR. Rationale: the precursor of RBC is the stem cells in the red marrow. 10. Answer A. Rationale: Stem cells erythroblast- reticulocyte erythrocytes. Erythropoietin is the hormone that stimulates red blood cell production in the red marrow. Mature red blood cells are formed from stem cells in the bone marrow. With the presence of erythropoietin, red cell pathway starts to form proerythroblast from stem cells. At this point the cell still contains nucleus. However, as the development progresses the nucleus becomes smaller and the cytoplasm becomes basophilic due to the presence of ribosome, thus the cell is now called basophilic erythroblast. As the cell becomes older it also becomes smaller and eventually when it begins to produce hemoglobin it is now termed as polychromatic erythroblast. Later on the cytoplasm will become more eosinophilic and the cell is now called orthochromatic erythroblast, which will then extrude its nucleus as the cells slowly fill with hemoglobin before entering the circulation as reticulocytes. Reticulocytes will mature to form the anucleated red blood cells. 11. Answer C. Keyword: TRUE. Rationale: Kidneys produce and release the hormone erythropoietin that is responsible for initiating the production of RBCs in the red marrow. Red blood cells are anucleated cells (without nucleus) and have a life span of 120 days or 4 months. 12. Answer A. Keyword: PASSES/CROSSES THE PLACENTA. Rationale: There is only one immunoglobulin that passes or crosses that placenta, the IgG. IgG starts to cross the placenta at the first trimester of pregnancy. However, the largest amount of IgG transfer is noted during the third trimester of pregnancy. This type of immunoglobulin provides the fetus a passive immunity to possible bacterial and viral infections. However, the passive immunity it provides is only temporary. The immunity gradually disappears at about 6 to 8 months of life. The gradual disappearance of passive immunity, leads to the gradual production of larger quantities of immunoglobulin to replace the IgG from the mother. 13. Answer C. Keyword: FIRST IMMUNOGLOBULIN PRODUCED BY THE BODY. Rationale: IgM is the first immunoglobulin produced by the body when the neonate is distressed, has acquired an infection or is challenged. When a newborn is exposed to environmental antigens, production of IgM rapidly increases. This type of immunoglobulin provides protection from gram-negative bacteria. IgM cannot cross the placental barrier. In cases where large amount of IgM is found in the placenta, possible exposure to infection in the utero is probable 14. Answer B. Keyword: HEMOGLOBIN SYNTHESIS. Rationale: Dietary elements are essential for RBC production. The following are needed by the red marrow to produce erythrocytes: Iron for hemoglobin synthesis Folic Acid for DNA synthesis Vitamin B12 for DNA synthesis 15. Answer D. Keyword: MOST AT RISK. Rationale: The elderly are most at risk for anemia often due to financial concerns affecting protein intake or poor dentition that interferes with chewing meat.

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16. Answer B. Keyword: DECREASED NUMBER OF PLATELETS. Rationale: thrombocytopenia is a decreased number of platelets. Thrombocytosis is an excess in the number of platelets. Thrombocytopathy is a platelet dysfunction. Thrombectomy is the surgical removal of a thrombus. 17. Answer C. Rationale: TO IMPROVE PLATELET COUNT. Rationale: Corticosteroid therapy can decrease antibody production and phagocytosis of the antibody-coated platelets, retaining more functioning platelets. Methotrexate can cause thrombocytopenia. Vitamin K is used to treat an excessive anticoagulable state from warfarin overload, and ASA decreases platelet aggregation. 18. Answer A. Keyword: B-CELLS. Rationale: B-Cells are responsible for humoral or immunoglobulin mediated immunity. T-cells are responsible for cell-mediated immunity. There is such thing as antigen-mediated immunity. 19. Answer D. Rationale: The life span of a normal platelet is 7-10 days. However, in idiopathic thrombocytopenia the life span is reduced to 1-3 days. 20. Answer D. Keyword: PRIMARILY. Rationale: SLE is a chronic, inflammatory, autoimmune disorder affecting primarily the connective tissues. It also affects the skin and kidneys and may affect the pulmonary, cardiac, neural and renal systems. 21. Answer C. Keyword: NEUROLOGICAL INVOLVEMENT. Rationale: neurologic involvement may be shown by: Psychosis Seizures Headaches 22. Answer A. Keyword: CLASSIC SIGN. Rationale: Although all these symptoms can be signs of SLE, the classic sign is the butterfly rash over the cheeks and nose. 23. Answer B. Keyword: SUPPORTS THE DIAGNOSIS. Rationale: lab findings for clients with SLE usually show: Pancytopenia Elevated ANA titer Decreased serum complement levels 24. Answer C. Keyword: AVOID. Rationale: a low-bacteria diet would be indicated. Raw fruits and vegetables are excluded in the clients diet. 25. Answer C. Keyword: AVERAGE LENGTH OF TIME. Rationale: epidemiologic studies show the average time from initial contact with HIV to the development of AIDS is 10 years. 26. ANSWER A An elevation in white blood cells may indicate that the client has an infection, which would likely require rescheduling of the surgical procedure. The other values are slightly abnormal, but would not be likely to cause post-operative problems for a knee arthroscopy. Focus: Prioritization 27. ANSWER C Normal saline, an isotonic solution, should be used when priming the IV line to avoid causing hemolysis of RBCs. Ideally, blood products should be infused as soon as possible after they are obtained; however, a 20-minute delay would not be unsafe. Large-gauge IV catheters are preferable for blood administration; if a smaller catheter must be used, normal saline may be used to dilute the RBCs. Although it is appropriate to instruct clients to notify the nurse if symptoms of a transfusion reaction such as shortness of breath or chest pain occur, it will cause unnecessary 20

anxiety to indicate that a serious reaction is likely to occur. Focus: Prioritization 28. ANSWER D Hypoxia and deoxygenation of the red blood cells are the most common cause of sickling, so administration of oxygen is the priority intervention here. Pain control and hydration are also important interventions for this client and should be accomplished rapidly. Vaccination may help prevent future sickling episodes by decreasing the risk of infection, but it will not help with the current sickling crisis. Focus: Prioritization 29. ANSWER A An experienced nursing assistant would have been taught how to obtain a stool specimen for the Hematoccult slide test, because this is a common screening test for hospitalized clients. Having the client sign an informed consent should be done by the physician who will be doing the colonoscopy. Administration of medications and checking for allergies are within the scope of practice for licensed nursing staff. Focus: Delegation 30. ANSWER C A nurse who works in the PACU will be familiar with the monitoring needed for a client who has just returned from a procedure like a colonoscopy, which requires conscious sedation. The other clients require more experience with various types of hematologic disorders and would be better to assign to nursing staff who regularly work on the medical surgical unit. Focus: Prioritization 31. ANSWER A Clients with pancytopenia are at higher risk for infection. The client with digoxin toxicity presents the least risk of infecting the new client. Viral pneumonia, shingles, and cellulites are infectious processes. Focus: Prioritization 32. ANSWER B The joint pain that occurs in sickle cell crisis is caused by obstruction to blood flow by the sickled red blood cells. The appropriate therapy for this client would be application of moist heat to the joints to cause vasodilation and improve circulation. Because control of pain is a priority during sickle cell crisis, there is no need to restrict all visitors or to check the temperature every 2 hours. Focus: Prioritization 33. ANSWER C Because aspiring will decrease platelet aggregation, clients with thrombocytopenia should not use aspirin routinely. Client teaching about his should be included in the care plan. Bruising is consistent with the clients admission problem of thrombocytopenia. Soft, dark brown stools indicate that there is no frank blood in the bowel movements. A decrease in appetite is common with chemotherapy, and more assessment is indicated. Focus: Prioritization 34. ANSWER B When a hemophiliac client is at high risk for bleeding, for example, after a motor vehicle accident, the priority intervention is to maximize the availability of clotting factors. The other orders also should be implemented rapidly, but do not have as high a priority. Focus: Prioritization 35. ANSWER A Clients taking warfarin are advised to avoid making sudden diet changes, because changing the oral intake of foods high in vitamin K (such as green leafy vegetables and some fruits) will have an impact on the effectiveness of the medication. The other statements suggest that further teaching may be indicated, but more assessment for teaching needs is indicated first. Focus: Prioritization 36. ANSWER C Because the decrease in oxygen saturation will have the greatest immediate effect on all body systems, improvement in oxygenation should be the priority goal of care. The other data also indicate the need for rapid intervention, but improvement of oxygenation is the most urgent need. Focus: Prioritization 21

37. ANSWER C Most assessment about what the client means is needed before any interventions can be planned or implemented. All of the other statements indicate a conclusion that the client is afraid of dying of Hodgkins disease. Focus: Prioritization 38. ANSWER D Any temperature elevation in a neutropenic client may indicate the presence of a life-threatening infection, so actions such as blood cultures and antibiotic administration should be initiated quickly. The other clients need to e assessed as soon as possible, but are not critically ill. Focus: Prioritization 39. ANSWER B Nursing assistant education include routine nursing skills such as assessment of vital signs. Evaluation, baseline assessment of client abilities, and nutrition planning are roles appropriate to RN practice. 40. ANSWER C The clients symptoms indicate that a transfusion reaction may be occurring so the first action should be to stop the transfusion. Chills are an indication of a febrile reaction, so warming the client is not appropriate. Checking the clients temperature and administration of oxygen are also appropriate actions if a transfusion reaction is suspected; however, stopping the transfusion is the priority. Focus: Prioritization Sources: http://www.ehow.com/list_7762630_specific-purposes-nursing-research.html http://www.researchinfoonline.com/nursing-research.html http://www.scribd.com/doc/11906224/MedicalSurgical-Nursing-Review http://nclexreviewers.com/nclex-review/hematologic-and-immune-system-disorders/nclexquestions-hematology-answers-and-rationale.html http://nclexreviewers.com/nclex-review/hematologic-and-immune-system-disorders/nclexquestions-hematology.html http://www.rnpedia.com/home/exams/medical-and-surgical-nursing-exams/hematologicproblems http://www.rnpedia.com/home/exams/medical-and-surgical-nursing-exams/hematologicproblems/answer-and-rationale---hematologic-problems

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