[Osborn] chapter 62

Learning Outcomes [Number and Title ]

Learning Outcome 1
Explain how the hematologic system functions in an adult.
Learning Outcome 2
Describe the types, characteristics, and functions of blood cells.
Learning Outcome 3
Explain how the process of coagulation works in the event of
an injury.
Learning Outcome 4
Describe appropriate nursing assessment/responsibilities
related to the hematologic system in the adult patient.
Learning Outcome 5
Describe laboratory tests used to evaluate the hematologic
system.
Learning Outcome 6
Distinguish between normal and abnormal test results for the
hematologic system.
Learning Outcome 7
Discuss the meaning of shift to the left.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
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1. Identify the key items that define how the hematologic system functions.
Select all that apply.
1. The main component of the system is blood.
2. Blood is a type of connective tissue.
3. The hematologic system is a transport system that functions to provide nutrients
to the body.
4. The hematologic system is a transport system that functions to remove toxins
from the body.
5. The lymphatic and the reticuloendothelial/mononuclear phagocyte systems
contribute to the functions of the hematologic system.
Correct Answer:
1. The main component of the system is blood.
2. Blood is a type of connective tissue.
3. The hematologic system is a transport system that functions to provide nutrients
to the body.
4. The hematologic system is a transport system that functions to remove toxins
from the body.
5. The lymphatic and the reticuloendothelial/mononuclear phagocyte systems
contribute to the functions of the hematologic system.
Rationale: The main component of the system is blood. Blood, which is composed of a
variety of cells and supportive fluids, is an obvious component of the hematologic
system. Blood is a type of connective tissue. Blood is identified as a type of connective
tissue that runs throughout the body. The hematologic system is a transport system
that functions to provide nutrients to the body. It provides a transport system that
delivers nutrition, oxygen, and secretory products throughout the body. The hematologic
system is a transport system that functions to remove toxins from the body. Blood
transports wastes to the kidneys and liver for disposal. The lymphatic and the
reticuloendothelial/mononuclear phagocyte systems contribute to the functions of
the hematologic system. The lymphatic system, the spleen, the liver and the
reticuloendothelial/mononuclear phagocyte system contribute to the overall function of
the hematological system. Second, the immunologic products of the hematologic system
are critical to the defense of the body.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

2. As a client ages, what changes are expected in the hematologic system?

Select all that apply.
1. The amount of red marrow and the number of stem cells decrease with aging.
2. As stem cells decrease in number, they are gradually replaced by nonfunctional fat
cells.
3. Hemoglobin levels tend to decrease after middle age, more so in men than women.
4. There may be some T-cell function loss that may account for a poor response to
immunizations.
5. Laboratory parameters change dramatically.
Correct Answer:
1. The amount of red marrow and the number of stem cells decrease with aging.
2. As stem cells decrease in number, they are gradually replaced by nonfunctional
fat cells.
3. Hemoglobin levels tend to decrease after middle age, more so in men than
women.
4. There may be some T-cell function loss that may account for a poor response to
immunizations.
Rationale: The amount of red marrow and the number of stem cells decrease with
aging. The amount of red marrow and the number of stem cells decrease with aging, but
the marrow is not completely depleted, even in very old adults. As stem cells decrease
in number, they are gradually replaced by nonfunctional fat cells. The remaining
stem cells retain their functional capacity to divide, but as they decrease in number, they
are gradually replaced by nonfunctional fat cells. Hemoglobin levels tend to decrease
after middle age, more so in men than women. It is recognized that hemoglobin levels
tend to decrease after middle age, more so in men than in women. There may be some Tcell function loss that may account for a poor response to immunizations. It has been
suggested that there may be some T-cell function loss and that this may account for a
poor response to immunizations. Laboratory parameters change dramatically.
Laboratory parameters as they relate to the hematologic system of aging clients usually
are not much different than those of a younger patient.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

3. When assessing a client for hematologic system status, the nurse should consider the
following:
Select all that apply.
1.
2.
3.
4.
5.

Family history
Presenting symptoms
Chief complaint
Prior episodes with bleeding
Physical examination findings

Correct Answer:
1. Family history
2. Presenting symptoms
3. Chief complaint
4. Prior episodes with bleeding
5. Physical examination findings
Rationale: Family history. Family history will assist the nurse in identifying potential
susceptibilities to hematologic disorders. Presenting symptoms. Assessment of
presenting symptoms will help pinpoint the source of problem. Chief complaint. Tells
the nurse in the clients own words and perceptions what is wrong. Prior episodes with
bleeding. Past history provides insight into current problem. Physical examination
findings. Physical examination may the pinpoint source of problem.
Cognitive level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing:

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Inc.

4. What phrases best describe the characteristics of red blood cells?

Select all that apply.
1. Carry oxygen to tissues
2. Maintain the chemical integrity of hemoglobin
3. Assume a flexible disk shape that allows for optimal filling and transport to
body tissues
4. Are terminally differentiated
5. Have a life span of approximately 90 days
Correct Answer:
1. Carry oxygen to tissues
2. Maintain the chemical integrity of hemoglobin
3. Assume a flexible disk shape that allows for optimal filling and transport to
body tissues
4. Are terminally differentiated
Rationale: Carry oxygen to tissues. This is a primary function of blood as a transport
system. Maintain the chemical integrity of hemoglobin. The function of the red blood
cells is to become filled with hemoglobin, maintain the integrity of hemoglobin, and
distribute it to the bodys tissues. Assume a flexible disk shape that allows for optimal
filling and transport to body tissues. The shape facilitates filling and transport of
nutrients. Are terminally differentiated. Red blood cells can never divide. Have a life
span of approximately 90 days. Actual life span is approximately 120 days.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

5. A client is admitted to the unit with a high count of lymphocytes. In reviewing the
laboratory findings, the nurse will expect to find the following in addition to the high
lymphocyte count:
Select all that apply.
1. A presence of T cells.
2. A presence of B cells.
3. A presence of natural killer cells (NK cells).
4. A presence of basophils.
5. A presence of thrombocytes.
Correct Answer:
1. A presence of T cells.
2. A presence of B cells.
3. A presence of natural killer cells (NK cells).
Rationale: A presence of T cells. Approximately 60% to 70% of blood lymphocytes are T
cells. A presence of B cells. Approximately 10% of blood lymphocytes are B cells. A
presence of natural killer cells (NK cells). Natural killer cells (NK cells) are a type of
lymphocytes that are functionally distinct from T and B cells. A presence of basophils.
Basophils are a different type of white blood cell than lymphocytes. A presence of
thrombocytes. Thrombocytes are a different type of cell that prevents blood from
clotting.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

6. A client with a family history of anemia is admitted to the unit. What type of blood cell
would be characteristic of an inherited type of anemia?
1.
2.
3.
4.

Sickle cell
Lymphocyte
Eosinophil
Reticulocyte

Correct Answer: Sickle cell

Rationale: The sickle cell is an abnormal cell, shaped like a sickle, and is unique to sickle
cell anemia, which may be inherited. Lymphocytes, platelets, and reticulocytes are
normal cells present in blood.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing:

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7. In the formation of platelets, the megakaryocyte:

1.
2.
3.
4.

Breaks into pieces called platelets.

Is a part of the formation of any cell type.
Is necessary for RBC formation.
Does not release platelets.

Correct Answer: Breaks into pieces called platelets.

Rationale: Megakaryocytes do break into pieces called platelets as part of the stem-cellto-thrombocyte formation process. The stem cell is the precursor cell of all blood
components (red blood cells, white blood cells, and platelets.) Megakaryocytes are not
responsible for RBC formation.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

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Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

8. Which of the following explains the difference between primary hemostasis and
secondary hemostasis?
Select all that apply.
1.
2.
3.
4.

Primary hemostasis is characterized by vascular contraction.

Primary hemostasis is characterized by platelet adhesion.
Primary hemostasis is the stage in which a soft aggregate plug is formed.
Secondary hemostasis is responsible for stabilizing the soft clot and maintaining
vasoconstriction.
5. The coagulation cascade is activated during primary hemostasis.
Correct Answer:
1. Primary hemostasis is characterized by vascular contraction.
2. Primary hemostasis is characterized by platelet adhesion.
3. Primary hemostasis is the stage in which a soft aggregate plug is formed.
4. Secondary hemostasis is responsible for stabilizing the soft clot and maintaining
vasoconstriction.
Rationale: Primary hemostasis is characterized by vascular contraction. Primary
hemostasis is characterized by vascular contraction, platelet adhesion, and formation of a
soft aggregate plug. Primary hemostasis is characterized by platelet adhesion Primary
hemostasis is characterized by vascular contraction, platelet adhesion, and formation of a
soft aggregate plug. Primary hemostasis is the stage in which a soft aggregate plug is
formed. Primary hemostasis is characterized by vascular contraction, platelet adhesion,
and formation of a soft aggregate plug. Secondary hemostasis is responsible for
stabilizing the soft clot and maintaining vasoconstriction. The clot is stabilized during
the secondary phase and is initiated when the coagulation cascade is activated at the time
of injury. The coagulation cascade is activated during primary hemostasis. The
coagulation cascade is activated during secondary hemostasis.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

9. Platelets aggregate in response to extrinsic factors that can be described as:

1.
2.
3.
4.

Trauma.
Bacteria.
Antibodyantigen reaction.
WBCs.

Correct Answer: Trauma.

Rationale: A blood vessel must incur an injury in order for hemostasis to be initiated.
Extrinsic factors refer to those outside of the blood vessel, such as an injury.
Bacteria, antibodyantigen reactions, and white blood cells would all represent
circulating proteins characteristic of intrinsic factors.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

10. Physical examination related to the hematologic system of the adult client should
include inspection of the:
Select all that apply.
1.
2.
3.
4.
5.

Skin.
Head and neck.
Chest.
Abdomen.
Feet and legs.

Correct Answer:
1. Skin.
2. Head and neck.
3. Chest.
4. Abdomen.
Rationale: Skin. Changes in skin color often indicate erythrocyte disorders such as
anemia. Head and neck. The structures of the head, particularly the eyes and mouth,
provide useful evidence in the evaluation of the patient. The neck should be inspected for
signs of lymph node enlargement or tenderness. Chest. Structures in the chest, heart, and
lymph nodes yield clues to hematologic system disorders; for example, tachycardia is a
response to both infection and anemia. Abdomen. Abdominal tenderness is a general
complaint that might be indicative of splenomegaly or hepatomegaly, both indicators of
increased blood destruction. Feet and legs. Feet and legs do not provide any specific
clues to hematologic problems.
Cognitive level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

11. Identify the major way that alcohol consumption can affect the hematologic system.
1.
2.
3.
4.

Nutritional deficiencies
Alteration in the clotting mechanism
Acceleration of ethrocyte formation
Acceleration of phagocytosis

Correct Answer: Nutritional deficiencies

Rationale: Excessive alcohol use results in vitamin deficiencies and potentially GI
damage that can suppress hematopoiesis. Alcohol does not affect the clotting mechanism,
erythocyte formation, or phagocytosis.
Cognitive level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

12. When assessing an older adult for possible hematologic problems, the nurse should
pay particular attention to:
Select all that apply.
1.
2.
3.
4.
5.

History of bleeding problems.

Presenting symptoms and chief complaint.
Presence of risk factors.
General physical appearance.
Laboratory parameters.

Correct Answer:
1. History of bleeding problems.
2. Presenting symptoms and chief complaint.
3. Presence of risk factors.
4. General physical appearance.
Rationale: History of bleeding problems. This provides clues as to possible current
problems. Presenting symptoms and chief complaint. These tell the nurse in the
patients own words what is wrong and alert the nurse to potential foci of current
problems, for example, RBCs or WBCs. Presence of risk factors. These make known an
individuals susceptibility to specific disorders. General physical appearance. This
conveys an impression of health status. Laboratory parameters. There is usually not
much difference in laboratory parameters of the aging client and younger clients.
Cognitive level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

13. Which of the following describes the difference between the hemoglobin and
hematocrit values of a complete blood count?
1. Hemoglobin is the amount of functional, or iron-containing, protein of the red
blood cell, whereas hematocrit represents the percentage of hemoglobin in a given
volume of blood.
2. Hemoglobin represents the percentage of functional protein of the red blood cell,
whereas hematocrit is an indicator of the amount of functional protein of the red
blood cell.
3. Hemoglobin values vary between men and women, but hematocrit values do not
vary between men and women.
4. Hemoglobin values tend to be higher for males, and hematocrit values tend to be
higher in females.
Correct Answer: Hemoglobin is the amount of functional, or iron-containing, protein of
the red blood cell, whereas hematocrit represents the percentage of hemoglobin in a
given volume of blood.
Rationale: Hemoglobin is the iron-containing protein that bonds with oxygen, allowing
the red blood cells to transport oxygen throughout the body. Normal values are higher for
men than for women. Hematocrit, sometimes called paced cell volume, measures the
portion of blood volume made up by red blood cells. Hematocrit values also tend to be
higher in men than in women.
Cognitive level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

14. Normal values of coagulation studies include:

Select all that apply.
1.
2.
3.
4.
5.

Prothrombin time (PT): 12 to 15 seconds.

Thrombin time: 8 to 12 seconds.
Fibrinogen: 200 to 400 mg/dL.
Activated partial thromboplastin tme (aPTT): 60 seconds.
Bleeding time: less than 1 minute.

Correct Answer:
1. Prothrombin time (PT): 12 to 15 seconds.
2. Thrombin time: 8 to 12 seconds.
3. Fibrinogen: 200 to 400 mg/dL.
Rationale: Prothrombin time (PT): 12 to 15 seconds. This value is within the correct
time parameters. Thrombin time: 8 to 12 seconds. This time is within the normal
parameters. Fibrinogen: 200 to 400 mg/dL. This value is within the normal parameters.
Activated partial thromboplastin time (aPTT): 60 seconds. This is too long; the
normal value is 30 to 45 seconds. Bleeding time: less than 1 minute. This is too short of
a time period; normal parameters are 1 to 6 minutes.
Cognitive level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

15. The differential blood count measures:

1. The percent of the five types of white blood cells in a sample of 100 white
blood cells.
2. Inflammation, infection, and response to therapy.
3. Volume of red blood cells in whole blood.
4. Number of thrombocytes in whole blood.
Correct Answer: The percent of the five types of white blood cells in a sample of 100
white blood cells
Rationale: The differential count measures the amount of different types of white blood
cells present in the blood sampleneutrophils, lymphocytes, monocytes, eosinophils,
and basophils. Inflammation, infection, and response to therapy are measured by the total
white blood cell count. A hematocrit count measures the volume of red blood cells in
whole blood. The number of thrombocytes in whole blood is measured by a platelet
count.
Cognitive level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

16. A decreased RBC count can be due to:

Select all that apply.
1. Bleeding that results in an abnormal loss of erythrocytes.
2. Abnormal destruction of erythrocytes.
3. Lack of needed hormones and elements for production of erythrocytes.
4. Bone marrow suppression.
5. An excessive production of hormones needed for the production of erythrocytes.
Correct Answer:
1. Bleeding that results in an abnormal loss of erythrocytes.
2. Abnormal destruction of erythrocytes.
3. Lack of needed hormones and elements for production of erythrocytes.
4. Bone marrow suppression.
Rationale: Bleeding that results in an abnormal loss of erythrocytes. This causes a
lowering of RBC count. Abnormal destruction of erythrocytes. This causes a lowering
of RBC count. Lack of needed hormones and elements for production of
erythrocytes. This causes a lowering of RBC count. Bone marrow suppression. This
causes a lowering of RBC count. An excessive production of hormones needed for the
production of erythrocytes. This would cause an increase in RBC count.
Cognitive level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

17. Identify which of the following disorders would result from a decrease in the number
of cells.
Select all that apply.
1.
2.
3.
4.
5.

Thrombocytopenia
Leukopenia
Polycemia
Splenomegaly
Myeloma

Correct Answer:
1. Thrombocytopenia
2. Leukopenia
Rationale: Thrombocytopenia. This is the presence of relatively few platelets in blood.
Leukopenia. This is a decrease in the number of circulating white blood cells.
Polycemia. This occurs when excess red blood cells are produced as a result of an
abnormality of the bone marrow. Splenomegaly. This is an enlargement of the spleen.
Myeloma. This is a form of bone cancer caused by a caused by overproduction of
immune cells in bone marrow.
Cognitive level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

18. A clients assessment data indicates a potential bleeding problem. What laboratory
studies will be used to isolate the problem?
Select all that apply.
1.
2.
3.
4.
5.

Platelet count
Prothrombin time (PT)
Bleeding time
Activated partial thromboplastin time (aPTT)
Fibrinogen split products

Correct Answer:
1. Platelet count
2. Prothrombin time (PT)
3. Bleeding time
4. Activated partial thromboplastin time (aPTT)
Rationale: Platelet count. The platelet count is a test that determines the number of
platelets in the blood, and depicts clotting potential. Prothrombin time (PT).
Prothrombin time depicts extrinsic coagulation factors. Bleeding time. Bleeding time
reflects platelet interaction and capillary constriction. Activated partial thromboplastin
time (aPTT). aPTT reflects intrinsic coagulation factors critical to the clotting cascade.
Fibrinogen split products. This is useful in detection of DIC, which is triggered by an
injury or event leading to persistent activation of the clotting cascade, not by a bleeding
problem per se.
Cognitive level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

19. When a shift to the left occurs, the nurse should consider the possibility of the
following disorders:
Select all that apply.
1.
2.
3.
4.
5.

Undetected infection.
Bone marrow disease.
Immune system insufficiencies.
Immunosuppressive therapies.
Presence of foreign cells in the bone marrow.

Correct Answer:
1. Undetected infection
2. Bone marrow disease
3. Immune system insufficiencies
4. Immunosuppressive therapies
Rationale: Undetected infection. A shift to the left is a compensatory mechanism to
combat infection. Bone marrow disease. A shift to the left may be indicative of bone
marrow disease. Immune system insufficiencies. A shift to the left may be indicative
of immune system insufficiencies caused by bone marrow disease. Immunosuppressive
therapies. A shift to the left may occur as a result of immunosuppressive therapies
such as chemotherapy. Presence of foreign cells in the bone marrow. A shift to the
left is not indicative of the presence of foreign cells in the marrow.
Cognitive level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 7

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

20. Which laboratory value is indicative of a shift to the left?

1.
2.
3.
4.

Increase in total white blood cell count

Increase in absolute neutrophils count (ANC)
Increase in platelets
Increase in erythrocytes

Correct Answer: Increase in total white blood cell count

Rationale: A shift to the left phenomenon represents an increase in the total white blood
cell count. The bone marrow is stimulated to release a large number of relatively
immature cells and juvenile cells as a compensatory mechanism to combat severe
infection. An increase in absolute neutrophils, platelets, and erythrocytes is not indicative
of a shift to the left.
Cognitive level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 7

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.

20. The health care provider should be notified immediately if a client experiences a
shift to the left in laboratory values because:
1.
2.
3.
4.

It is an indicator of risk for a severe infection.

It is an indicator of a potential bleeding problem.
It is an indicator of electrolyte imbalance.
It is an indicator of disruption of hemostasis.

Correct Answer: It is an indicator of risk for a severe infection.

Rationale: During a shift to the left, the bone marrow is stimulated to release a large
number of relatively immature cells and juvenile cells as a compensatory mechanism to
combat severe infection. In an otherwise healthy individual, this may signal an early sign
of an otherwise undetected infection, and the client may not have sufficient host defenses.
A shift to the left does not pertain to potential bleeding problems, electrolyte
imbalance, or hemostasis disruption.
Cognitive level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 7

Osborn, et al., Test Item File for Medical-Surgical Nursing:

Preparation for Practice Copyright 2010 by Pearson Education,
Inc.