Chapter 27. Hematologic and Lymphatic System Function, Assessment, and Therapeutic Measures My Nursing Test Banks

Chapter 27. Hematologic and Lymphatic System Function, Assessment, and Therapeutic Measures

Multiple Choice
Identify the choice that best completes the statement or answers the question.

____ 1. The nurse is concerned that a patient is demonstrating signs of red blood cell production. What laboratory value did the nurse most likely use to make this decision?
a. Iron
b. Bilirubin
c. Thrombin
d. Intrinsic factor
____ 2. The nurse notes that a patients gaping wound is developing a blood clot. Which body substance is responsible for this clot formation?
a. Plasma
b. Platelets
c. Red blood cells
d. White blood cells
____ 3. A nurse is preparing to assist with a bone marrow biopsy. Which anatomical site should the nurse anticipate will be used to obtain the specimen?
a. Ribs
b. Humerus
c. Posterior iliac crest
d. Long bones in the legs
____ 4. The nurse is reviewing the parts of the complete blood count and differential with a patient. Where should the nurse state that neutrophils, eosinophils, and basophils are produced?
a. Spleen
b. Thymus
c. Lymph nodes
d. Red bone marrow
____ 5. The nurse is explaining the role of red blood cells with oxygen transport in the body with a nursing student. Which term should the nurse use to describe hemoglobin that has given up its oxygen to the bodys cells?
a. Reduced
b. Detached
c. Oxyhemoglobin
d. Hypoxyhemoglobin
____ 6. A patient is admitted to determine why red blood cells are being quickly destructed in the body. What finding should the nurse associate with this patients health problem?
a. Jaundice
b. Bleeding
c. Diarrhea
d. Cyanosis
____ 7. A patient has an altered level of T and B cells. The nurse realizes that these cells are members of which cell type?
a. Platelets
b. Eosinophils
c. Lymphocytes
d. Red blood cells
____ 8. A patient with a bleeding disorder is prescribed an infusion of plasma. What should the nurse explain as being the purpose of this infusion?
a. Contains clotting factors
b. Carries oxygen to the tissues
c. Supports cellular metabolism
d. Removes waste products from cells
____ 9. A patient with abdominal injuries from a motor vehicle crash is scheduled for surgery to remove the spleen. What bodily function will be affected by the removal of this organ?
a. Filtration of waste products
b. Removal of old red blood cells from circulation
c. Clearance of mucous in the tracheobronchial tree
d. Facilitation of glucose to be used by the cell for energy
____ 10. The nurse is documenting findings after completing data collection with a patient. What term should the nurse use to document a large area of discoloration from hemorrhage under the skin?
a. Pallor
b. Rubor
c. Petechiae
d. Ecchymosis
____ 11. The nurse is assessing a patient with chronic lung disease. Which finding indicates long-term hypoxia?
a. Pallor
b. Dyspnea
c. Clubbed fingertips
d. Pulmonary crackles
____ 12. The nurse is caring for a patient having a bone marrow biopsy. What nursing action is the most important following the biopsy?
a. Observe for bleeding.
b. Encourage oral fluids.
c. Administer an analgesic for pain.
d. Monitor the puncture site for infection.
____ 13. A patient has a bone marrow aspiration from the posterior iliac crest. Before the procedure, the patients vital signs were: blood pressure 132/82 mm Hg and pulse 88 beats/min. One hour after the procedure, the blood pressure is 108/70 mm Hg and pulse is 96 beats/min. Which assessment is the least important for the patient at this time?
a. Observe the puncture site.
b. Check the patients most recent complete blood count report.
c. Ask the patient about feelings of lightheadedness or dizziness.
d. Determine if the patient had any medications before the procedure.
____ 14. A patient who is taking warfarin (Coumadin) 5 mg daily has an international normalized ratio (INR) of 2.5. It is time to administer the next dose of Coumadin. What should the nurse do?
a. Notify the physician STAT.
b. Hold the dose of Coumadin.
c. Prepare to administer vitamin K.
d. Administer the daily Coumadin as ordered.
____ 15. The nurse is staying with a patient who has been started on a blood transfusion. Which assessment should the nurse perform during a blood product infusion to detect a reaction?
a. Vital signs
b. Skin turgor
c. Bowel sounds
d. Pupil reactivity
____ 16. The nurse is monitoring a patient receiving a blood product and is concerned that the blood is going to deteriorate before it is complete infused. What is the maximum time that blood can hang during infusion before it begins to deteriorate?
a. 1 hour
b. 2 hours
c. 3 hours
d. 4 hours
____ 17. A patient receiving blood begins complaining of severe chest pain and a feeling of warmth. What should the nurse do first?
a. Call the physician.
b. Administer diuretics as ordered.
c. Discontinue the blood transfusion.
d. Assess vital signs and cardiovascular status.
____ 18. A patient is prescribed to receive 2 units of packed red blood cells. What approach should the nurse use to ensure that the correct blood will be provided to this patient?
a. Check the patients arm band.
b. Check the order on the medical record.
c. Follow the organizations verification process.
d. Assume the correct blood was provided by the blood bank.
____ 19. A patient is being prepared to receive a prescribed blood transfusion. What is the best way that the LPN can assist the health team to prevent a transfusion reaction?
a. Monitor vital signs every 15 minutes.
b. Warm blood to 98.6F (37C) before infusion.
c. Administer diphenhydramine (Benadryl) before the infusion.
d. Assist the registered nurse (RN) to identify correctly the patient and the blood product.
____ 20. A patient receiving blood complains of dyspnea. The nurse auscultates the patients lungs and finds crackles that were not present before the start of the transfusion. Which type of reaction should the nurse suspect?
a. Urticarial
b. Hemolytic
c. Anaphylactic
d. Circulatory overload
____ 21. The nurse is caring for a patient who has a white blood cell (WBC) count of 8000/mm3. What concern should the nurse have about this finding?
a. The patient has an infection.
b. The patient is at risk for infection.
c. The patient has a hematological disorder.
d. There is no concern; this is a normal finding.
____ 22. The nurse is reviewing the results of a patients arterial blood gas analysis. What should the nurse recognize as being a normal blood pH?
a. 7.29
b. 7.31
c. 7.38
d. 7.48
____ 23. An older adult patient is receiving a transfusion of packed red blood cells after being injured in a car accident. On assessment, the nurse notes a new finding of bounding pulse, crackles, and increasing dyspnea. What should the nurse do first, after stopping the transfusion?
a. Assess vital signs.
b. Raise the head of the bed.
c. Encourage the patient to deep breathe and cough.
d. Administer prn diphenhydramine (Benadryl) as ordered.
____ 24. A patient who underwent lymphangiography the day before asks the licensed practical nurse (LPN), Why does my urine look blue? What should the LPN respond to this patients concern?
a. It is nothing to be concerned about.
b. I will notify the RN and physician immediately.
c. This indicates that the procedure found abnormal results.
d. The dye used in the procedure may cause bluish skin and urine for 2 days.
____ 25. A patient is prescribed a transfusion of washed packed red blood cells. What should the nurse realize as being the rationale for the using this type of blood?
a. Reduces the risk of hypothermia
b. Cleans the blood cells of impurities
c. Reduces the risk of a febrile reaction
d. Removes potential harmful particles from the blood
____ 26. A patient reports severe abdominal cramping and diarrhea. Assessment reveals a temperature of 102F (38.8C) and pulse of 82 beats/min. Results of a complete blood count reveal lower than normal segmented and banded neutrophils and higher than normal lymphocytes. Which type of infection does the nurse suspect this patient is most likely experiencing?
a. Viral
b. Fungal
c. Parasitic
d. Bacterial
____ 27. The nurse is reviewing the activated partial thromboplastin time for a patient receiving heparin. Which value indicates that the medication is within the therapeutic range?
a. 2.5 to 9.5 minutes
b. 9.5 to 11.3 seconds
c. 1.5 to 2.0 times normal
d. 2.0 to 3.0 times normal
____ 28. The nurse is assisting with the preparation of a blood transfusion for a patient. Which type of fluid should the nurse select to transfuse with the blood?
a. 0.9% normal saline
b. Dextrose 5% and water
c. Dextrose 5% and 0.9% normal saline
d. Dextrolse 5% and 0.45% normal saline
____ 29. A female patients hematocrit level is 50% and oxygen saturation is 98% on room air. What should the nurse suspect as being the cause for this patients hematocrit level?
a. Dehydration
b. Chronic renal failure
c. Bone marrow suppression
d. Bleeding esophageal varices
____ 30. A patient has a platelet count of 75,000 /mm3. What action should the nurse take to support this patient?
a. Restrict blood draws.
b. Place in protective isolation.
c. Wear a mask when entering the room.
d. Document rectal temperatures to be taken.
____ 31. The nurse is assisting with the collection of data from a patient with a hematologic disorder. On which body system should the nurse expect to focus when collecting this data?
a. Respiratory
b. Genitourinary
c. Cardiovascular
d. All body systems
Multiple Response
Identify one or more choices that best complete the statement or answer the question.

____ 32. The nurse is evaluating laboratory values for a group of patients. Which values should the nurse identify as being within normal limits? (Select all that apply.)
a. An adult male with Hct = 35%
b. An adult female with Hct = 40%
c. An adult male with Hgb = 12.8 g/100 mL
d. An adult female with Hgb = 11.5 g/100 mL
e. An adult male with RBC = 4 million/mm3
f. An adult female with RBC = 5 million/mm3
____ 33. The nurse is reviewing the contents of blood plasma prior to participating in a seminar for nursing students. What should the nurse include as proteins in the plasma? (Select all that apply.)
a. Iron
b. Albumin
c. Globulin
d. Fibrinogen
e. Electrolytes
f. Hemoglobin
____ 34. A patient with a bleeding disorder is considering surgery to have the spleen removed. What should the nurse explain as being functions of the spleen in a healthy adult? (Select all that apply.)
a. Storage of platelets
b. Formation of bilirubin
c. Production of red blood cells
d. Production of neutrophils and eosinophils
e. Production of lymphocytes and monocytes
f. Phagocytosis of worn blood cells and platelets
____ 35. A patient with type O+ blood is to receive 4 units of packed red blood cells. Which type of blood should the nurse expect to see prepared for this patient? (Select all that apply.)
a. Type A+
b. Type AB-
c. Type O+
d. Type O-
e. Type B-
f. Type A-
____ 36. While receiving a unit of packed red blood cells, the patient begins to experience hives around the neck and upper chest. What actions should the nurse perform because of this reaction? (Select all that apply.)
a. Stop the transfusion.
b. Notify the health care provider (HCP).
c. Return the blood to the blood bank.
d. Administer prescribed antihistamines.
e. Restart the infusion and carefully monitor.
____ 37. A patient receiving a unit of packed red blood cells as treatment for anemia begins to vomit and experience extreme gastrointestinal cramping. What should the nurse do? (Select all that apply.)
a. Stop the transfusion.
b. Administer intravenous (IV) heparin.
c. Prepare to provide cardiopulmonary resuscitation (CPR) if necessary.
d. Stay with the patient and call for help.
e. Flush the blood tubing with normal saline.

Chapter 27. Hematologic and Lymphatic System Function, Assessment, and Therapeutic Measures
Answer Section

MULTIPLE CHOICE

1. ANS: B
The heme unit from RBC destruction forms bilirubin. B. Iron is not a value used to determine red blood cell destruction. C. Thrombin is involved in clotting. D. Intrinsic factor is a chemical produced by the parietal cells of the stomach lining that promote absorption of vitamin B12.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

2. ANS: B
Platelets are formed in the red bone marrow. They are fragments of large cells and are involved in all mechanisms of hemostasis: vascular spasm, platelet plugs, and chemical clotting. A. Plasma is not responsible for clot formation. C. D. Red and white blood cells may arrive to a site of injury however are not responsible for clot formation.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

3. ANS: C
An accurate bone marrow specimen in an adult can be obtained from the sternum, the spinous processes of the vertebrae, or the anterior or posterior iliac crests. A. B. D. The ribs, humerus, and long bones in the legs are not used for a bone marrow biopsy.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

4. ANS: D
The granular white blood cells neutrophils, eosinophils, and basophils are produced in the red bone marrow. B. T lymphocytes complete their development in the thymus. A. C. The T lymphocytes and B lymphocytes become activated, proliferate, and differentiate in the lymph nodes, spleen, and lymphatic nodules.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

5. ANS: A
Once hemoglobin gives up its oxygen to the cells of the body, it becomes reduced hemoglobin. C. Oxyhemoglobin is formed in the pulmonary capillaries where the hemoglobin combines with the oxygen in the lungs. B. D. Detached and hypoxyhemoglobin are not terms used to describe hemoglobin that has released oxygen into body cells.

PTS: 1 DIF: Moderate
KEY: Client Need: Health Promotion and Maintenance | Cognitive Level: Application

6. ANS: A
Red blood cells live for about 120 days and then become fragile and are phagocytized by fixed macrophages in the liver, spleen, and red bone marrow. Red blood cells destroyed sooner can cause jaundice to occur in the patient. B. C. D. Bleeding, diarrhea, and cyanosis are not manifestations associated with red blood cell destruction.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

7. ANS: C
There are two groups of lymphocytes: T cells and B cells. B. Eosinophils are granular white blood cells. A. D. Red blood cells and platelets are not types of white cells.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

8. ANS: A
Plasma is about 91% water. Plasma proteins are synthesized by the liver and include clotting factors, albumin, and globulins. A. Red blood cells carry oxygen to the tissues. C. D. A variety of substances support cellular metabolism and remove waste products from cells.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

9. ANS: B
The spleen contains fixed macrophages that phagocytize pathogens and worn or defective blood cells and platelets. A. The kidneys filter waste products. C. The lungs clear mucous in the tracheobronchial tree. D. The pancreas facilitates glucose to be used by the cell for energy.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

10. ANS: D
Ecchymoses are large areas of discoloration from hemorrhage under the skin. A. Pallor is paleness. B. Rubor is generalized redness. C. Petechiae are small purplish hemorrhagic spots under the skin.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

11. ANS: C
Clubbed fingertips and raised nail beds may indicate long-term hypoxia which can be caused by anemia. A. B. D. Crackles, dyspnea, and pallor can all indicate respiratory pathology but not necessarily long-term disease.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Analysis

12. ANS: A
Following biopsy, the nurse observes the aspiration site for bleeding and infection. Because bleeding is the most immediately life-threatening, it takes first priority. B. C. Pain control and fluids are also important, but they are not the most immediately life threatening. D. Infection at the site will not occur immediately after the procedure.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

13. ANS: B
The most recent blood count is not immediately helpful unless it is used to compare with a new, post-biopsy report. A. C. D. The vital signs indicate a change in status following the biopsypossible causes include bleeding from the site or a medication response. Symptoms of low blood pressure include lightheadedness or dizziness.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

14. ANS: D
The INR therapeutic range is 2 to 3, so 2.5 is where it should be, and the Coumadin can be administered. A, B, and C would be appropriate for an elevated INR.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

15. ANS: A
Changes in vital signs can signal onset of transfusion reaction. B. C. D. Bowel sounds, pupils, and skin turgor are not generally affected with a transfusion reaction.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

16. ANS: D
Generally, 2 hours is a good time frame to transfuse each unit of packed cells. If it must transfuse more slowly because of the patients condition, make sure that the unit does not hang longer than 4 hours. After that time, the blood is too warm and begins to deteriorate. A. C. Blood will not deteriorate if hanging for 1 or 3 hours.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

17. ANS: C
The nurse will likely carry out all the actions, but the blood must be discontinued first, to stop the source of the reaction. A. The physician can be notified after the blood is stopped. D. The nurse will continue to measure vital signs and cardiovascular status after the infusion is stopped. B. The nurse will provide medication therapy as prescribed but only after the infusion has been stopped.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

18. ANS: C
Before initiating a blood or blood component transfusion, the blood should be matched with the order, matched with the patient, verified using a two-person or one-person process with bar coding, and verified according to the organizations verification process. A. B. More than the patient arm band and order need to be checked. D. The nurse should never assume that the blood bank has provided the correct blood for a patient.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

19. ANS: D
Correct identification is essential to all blood transfusions. A. B. C. Warming blood, administering diphenhydramine, and frequent vital sign monitoring may be appropriate in specific cases but are not the best way to prevent reactions in most patients.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

20. ANS: D
Crackles and dyspnea indicate fluid in the lungs, a sign of circulatory overload. A. B. C. These are not typical symptoms of anaphylactic, urticarial, or hemolytic reactions.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

21. ANS: D
A normal WBC count is 5000 to 10,000/mm3. 8000 is not a concern. A. A high count is a sign of infection. B. A low count places a patient at risk for infection. C. Any variation from normal may signal a hematological disorder.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

22. ANS: C
The normal pH range of blood is 7.35 to 7.45 A. B. A pH less than 7.35 is acidic. D. A pH of 7.48 is alkaline.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

23. ANS: B
Older patients have less cardiac and renal ability to adapt to changes in blood volume, so they have a much higher risk of fluid overload when receiving blood transfusions. New onset of dyspnea, crackles, hypertension, or bounding pulse should be reported to the RN or physician immediately. Raising the head of the bed will help ease breathing. D. Diphenhydramine is helpful for allergic reactions. A. C. Assessing vital signs and encouraging deep breathing and coughing may be helpful, but the first priority is positioning the patient to breathe more easily.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPhysiological Adaptation | Cognitive Level: Application

24. ANS: D
Lymphangiography uses a dye that may turn skin, urine, or feces blue-tinged for about 2 days. B. There is no reason to notify the RN or physician. C. It is inappropriate to advise the patient about results and incorrect that it indicates an abnormal finding. A. Stating that it is nothing to be concerned about does not address the patients concern.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

25. ANS: C
The washing process removes almost all the plasma and can decrease the risk or severity of a febrile reaction. A. Hypothermia risk is reduced by warming blood. B. There is no process that removes impurities from cells. D. Harmful particles can be removed with filtering.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

26. ANS: A
Lymphocytes fight viral infections and are elevated during a virus. Segmented and banded neutrophils are elevated with bacterial infection. B. There are no particular white blood cell level changes associated with fungal infections. C. Eosinophils respond to parasitic infections.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

27. ANS: C
For a patient receiving heparin the therapeutic range for the activated partial thromboplastin time is 1.5 to 2.0 times normal. A. A normal bleeding time is 2.5 to 9.5 minutes. B. A normal prothrombin time for a female is 9.5 to 11.3 seconds. D. For a patient taking warfarin the therapeutic range for The INR is 2.0 to 3.0 times normal.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

28. ANS: A
Only normal saline solution is compatible with a blood transfusion. B. C. D Solutions that contain dextrose can cause red cells to lyse.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

29. ANS: A
Hematocrit levels are increased in chronic hypoxia and dehydration. Since the oxygen saturation level is 98% on room air, the nurse should suspect that this patient is dehydrated. B. C. D. The hemoglobin level will most likely be low if the patient has chronic renal failure, bone marrow suppression, or bleeding esophageal varices.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

30. ANS: A
A normal platelet count is 150,000450,000/mm3. There is an increased risk of bleeding with a low platelet count. The patients blood draws should be limited because of the risk of bleeding after a venipuncture. B. C. Protective isolation and wearing a mask would be appropriate if the white blood cell count was low. D. Rectal temperatures would be contraindicated in the patient with a low platelet count because of the risk for rectal bleeding.

PTS: 1 DIF: Moderate
KEY: Client Need: Safe and Effective Care EnvironmentSafety and Infection Control | Cognitive Level: Application

31. ANS: D
A hematologic disorder can affect all body systems. The nurse should collect data on as many body systems as possible. A. B. C. Hematologic disorders affect body systems other than the respiratory, genitourinary, and cardiovascular systems.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

MULTIPLE RESPONSE

32. ANS: B, F
Normal red blood cell (RBC) count for males is 4.6 to 6.2 million/mm3 and for females is 4.2 to 5.4 million/mm3. Normal hematocrit (Hct) for males is 40% to 54% and for females is 38% to 47%. Normal hemoglobin (Hgb) for males is 13.5 to 18 g/100 mL and for females is 12 to 16 g/100 mL.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

33. ANS: B, C, D
Plasma proteins include clotting factors, albumin, and globulins. Clotting factors, such as prothrombin and fibrinogen, are synthesized by the liver and circulate until activated in the clotting mechanism. Albumin, also synthesized by the liver, helps maintain blood volume and blood pressure by pulling tissue fluid into the venous ends of the capillary networks. Alpha and beta globulins are synthesized by the liver to be carrier molecules for substances such as fats, and gamma globulins are the antibodies produced by lymphocytes. A. E. F. Electrolytes and iron are not proteins, and hemoglobin is in red blood cells, not plasma.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

34. ANS: A, B, E, F
The spleen contains B cells and T lymphocytes, which mediate immune responses. It also contains fixed macrophages that phagocytize pathogens and worn or defective blood cells and platelets. The heme unit from red blood cell destruction forms bilirubin. Bilirubin is sent to the liver by way of portal circulation for excretion in the bile. The spleen also stores up to one-third of the bodys platelets. C. Red blood cells are produced in the bone marrow, not the spleen. D. Neutrophils and eosinophils are produced in the red bone marrow, not in the spleen.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Application

35. ANS: C, D
The ABO type (A, B, O, or AB) indicates the antigens present (or not present, as in the case of type O) on the red blood cells. In the plasma are antibodies for antigens that are not present in the blood. Type O blood therefore has antibodies to all blood types except type O, so type O is the only type that is safe to transfuse.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityReduction of Risk Potential | Cognitive Level: Analysis

36. ANS: A, B, D, E
On discovery of a urticarial reaction, the nurse should stop the transfusion and notify the HCP immediately. Expect that the patient will be given a dose of an antihistamine, such as diphenhydramine (Benadryl). If the transfusion is restarted, continue to monitor the patient closely. C. The blood will most likely not be returned to the blood bank but transfused into the patient.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

37. ANS: A, C, D
Anaphylactic reactions are not common but may be seen more often in patients who have received many transfusions. In this type of reaction, the very first milliliters of blood containing the allergens to pass into the patients system may be enough to cause the patient to develop respiratory or cardiovascular collapse. Other more common symptoms include severe gastrointestinal cramping and instant vomiting. The nurse should stop the transfusion at once and stay with the patient. Have someone else notify the RN and the HCP. Provide CPR if necessary. B. IV heparin is not used to treat this blood reaction. E. Flushing the blood tubing with normal saline will not help reduce the effects of this transfusion reaction.

PTS: 1 DIF: Moderate
KEY: Client Need: Physiological IntegrityPharmacological and Parenteral Therapies | Cognitive Level: Application

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