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The Client with White Blood Cell Disorders
55. The nurse notes that the daily white blood cell (WBC) count in a client with aplastic anemia has dropped overnight from 3,900 to 2,900/pL.
What is the appropriate nursing intervention?
1. Continue monitoring the client.
2. Call the laboratory to verify the report.
3. Document the finding.
The client will continue to be monitored, the laboratory may be called,
and the report will be placed on the chart,
but protection of the client must be instituted immediately.
4. Call the physician and place the client in reverse isolation.
The client will need an order to be placed in reverse (protective) isolation because his normal defenses are ineffective and place him at risk for infection (leukopenia, less than 5,OOO/pL).
The faster the decrease in WBCs, the greater the bone marrow suppression,
and the more susceptible the client is to infection from not only pathogenic
but nonpathogenic organisms.
56. A client who had an exploratory laparotomy 3 days ago has a WBC differential with a shift to the left. The nurse instructs unlicensed personnel to report which clinical manifestation?
1. Swelling around the incision.
2. Redness around the incision.
3. Elevated temperature.
4. Purulent wound drainage.
A shift to the left means that more immature than mature WBCs are at the site of inflammation or infection. Immature WBCs are less effective at phagocytosis and do not produce classic signs of inflammation such as pus, redness, swelling, or heat. Fever is the only sign, and therefore it is a significant sign of infection in a client with immature or depressed WBCs.
57. What does the nurse calculate as the absolute neutrophil count (ANC) for a client with a WBC count of 1,200/micro L with bands, 1%; neutrophils, 34%; eosinophils, 3%; and basophils, 4%?
1. 440.
2. 420.
3. 468.
4. 456.
The ANC is calculated by multiplying the total WEC count by the sum of percentage of neutrophils and the percentage of bands and dividing by 100.
In this case,
1,200 (l + 34) = 420.100
58. A client with neutropenia has an ANC of 900. What is the client's risk of infection?
1. Normal risk.
The client is at normal risk of infection if the ANC is 1,500 or greater.
2. Moderate risk.
A client is at moderate risk when the ANC is less than 1,000.
The ANC decreases proportionately to the increased risk of infection.
3. High risk.
The client is at high risk of infection if the ANC is less than 500.
4. Extremely high risk.
An ANC of 100 or less is life-threatening.
59. What factor besides the degree of neutropenia does the nurse assess in determining the client's risk for infection?
1. Length of time neutropenia has existed.
The one factor that may be more important than the degree of neutropenia in determining the risk for infection is the duration of the neutropenia.
2. Health status before neutropenia.
3. Body build and weight.
4. Resistance to infection in childhood.
60. What nursing action is important in preventing cross-contamination?
1. Change gloves immediately after use.
Bedside rails, call bells, drug-administration controls operated by the patient, and other surface areas are frequently touched by caregivers with used gloves.
Changing gloves immediately after use protects the client from contamination by organisms.
Cross contamination is a break in technique of serious consequence
to the severely compromised client.
2. Stand 2 feet from the patient.
3. Speak minimally when in the room.
4. Wear long-sleeved shirts.
Standing two feet from the patient, speaking minimally, and wearing long-sleeved shirts are not required in standard interventions for risk of infection.
61. The nurse should teach the neutropenic client and the family
to avoid which of the following?
1. Using suppositories or enemas.
The neutropenic client is at risk for infection, especially bacterial infection of the respiratory and gastrointestinal tracts. Breaks in the mucous membranes, such as those that could be caused by the insertion of a suppository or enema tube, would be a break in the first line of the body's defense and a direct port of entry for infection.
2. Using a high-efficiency particulate air (HEPA) filter mask.
The client with neutropenia is encouraged to wear a HEPA filter mask and to use an incentive spirometer for pulmonary hygiene.
3. Performing perineal care after every bowel movement.
The client needs to know the importance of completing meticulous total body hygiene daily, including perianal care after every bowel movement, to decrease the flora at normal body orifices.
4. Performing oral care after every meal.
The client also needs to know the importance of performing oral care after every meal and every 4 hours while the client is awake to decrease the bacterial buildup in the oropharynx.
62. The nurse should remind family members who are visiting a client with granulocytopenia to
1. visit only if they do not have a cold.
2. wash their hands.
The Centers for Disease Control advises that washing hands
before, during, and after care has a significant effect in reducing infections.
It is advisable to avoid introducing a cold or children's germs and to avoid kissing on the lips, but the primary prevention technique is handwashing.
3. leave the children at home.
4. avoid kissing the client on the lips.
63. The nurse should remind the unlicensed personnel that which of the following is the most important goal in the care of the neutropenic client in isolation?
1. Listening to the client's feelings of concern.
2. Completing the client's care in a non-hurried manner.
3. Completing all of the client's care at one time.
It is important to acknowledge the client's concerns and fears and to provide organized, nonhurried, caring care, but it is more important to teach the client how to prevent an infection that could be life-threatening.
4. Instructing the client to dispose of tissue after blowing the nose.
The most common source of infection and microbial colonization in neutropenic clients is their own nonpathogenic normal flora.
Attention to personal hygiene such as oral, pulmonary, urinary, and rectal care is essential.
64. The nurse's role in the consent for the bone marrow aspiration
includes all of the following except
3. explaining the risks of the procedure to the client.
The nurse's role does not include explaining the risks of the procedure and giving the informed consent.
This is the role of the person who is to perform the procedure,
such as the doctor.
1. witnessing the client sign the consent form for the bone marrow aspiration.
2. evaluating that the client has a congruent understanding of the bone marrow aspiration procedure.
4. verifying that the client is signing the consent form by his or her free will.
One of the nurse's roles is to witness the client's signing of the consent form. The nurse also ascertains whether the client has an understanding that is consistent with the procedure listed on the form and determines that the client is signing the consent of his or her own free will.
65. A client is about to undergo bone marrow aspiration of the sternum.
Which of the following statements would the nurse include to provide sensory information to the client?
1. "You may feel a warm solution being wiped over your entire front
from your neck down to your navel and out to your shoulders."
A small area over the sternum is cleaned with an antiseptic.
It is unnecessary to paint the entire anterior chest.
2. "You will not feel the local anesthetic being applied because it will be sprayed on."
The local anesthetic is injected through the subcutaneous tissue to numb the tissue for the larger-bore needle that is used for aspiration and biopsy.
3. "You will feel a pulling type of discomfort for a few seconds."
As the bone marrow is being aspirated, the client will feel a suction or pulling type of sensation or discomfort that lasts a few seconds. A systemic premedication may be given to decrease this discomfort.
4. "After the needle is removed, a bandage will be applied around your chest
for the first 24 hours."
After the needle is removed, pressure is held over the aspiration site for 5 to 10 minutes to achieve hemostasis. A small dressing is applied; a large pressure dressing, such as an Ace bandage, would restrict the expansion of the lungs and is not used.
66. Twenty-four hours after a bone marrow aspiration,
the nurse evaluates which of the following as an appropriate client outcome?
1. The client maintains bed rest.
For a short period after the procedure, bed rest may be ordered.
2. There is redness and swelling at aspiration site.
Signs of infection such as redness and swelling
are not anticipated at the aspiration site.
3. The client requests morphine sulfate 2 mg 1M every 2 hours.
A mild analgesic may be ordered.
If the client continues to need the morphine for longer than 24 hours,
the nurse should suspect that internal bleeding or increased pressure
at the puncture site may be the cause of the pain
and should consult with the physician.
4. There is no bleeding at aspiration site.
After a bone marrow aspiration,
the puncture site should be checked every 10 to 15 minutes for bleeding.
67. A client states, "I don't want any more tests. Who cares what kind of leukemia I have? I just want to be treated now." What is the nurse's best response?
1. ''I'm sure you are frustrated and want to be well now."
The nurse should not label the client's feeling such as frustration or emotional; only the client can identify her own feelings.
2. "Your treatment can be more effective if it is based on more specific information about your disease."
The nurse is an advocate for the client with leukemia who can be empowered with knowledge of the treatment. Immunologic, cytogenic, morphologic, histochemical, and other means are used to identify cell subtypes and stages of leukemia cell development for very specific and optimal treatment.
3. "Now, you know the tests are necessary and that you are just upset right now.
Chastising the client is not helpful. It disavows the client's emotional state and responses to her diagnosis and involved treatment.
4. "I understand how you feel."
Unless nurses have had leukemia, they cannot possibly know
how the client feels even though they may be trying to offer her empathy.
68. During the induction stage for treatment of leukemia,
the nurse should remove which items that the family has brought into the room?
1. A Bible.
2. A picture.
3. A sachet (packet) of lavender (blue).
The induction phase of chemotherapy is an aggressive treatment to kill leukemia cells. The client is severely immunocompromised and severely at risk for infection. Flowers, herbs, and plants should be avoided during this time.
4. A hairbrush.
The client's Bible, pictures, and other personal belongings can be cleaned before being brought into the room to prevent contact with pathogenic and nonpathogenic organisms.
69. The nurse identifies deficient knowledge when the client undergoing induction therapy for leukemia makes which of the following statements?
1. "I will have to pace my activities with rest periods."
The induction therapy will cause anemia, and the client will experience fatigue and will have to pace activities with rest periods.
2. "I can't wait to get home to my cat!"
The nurse identifies that the client does not understand that contact with animals must be avoided because they carry infection and the induction therapy will destroy the client's WBCs.
3. "I will use warm saline gargle instead of brushing my teeth."
Platelet production will be decreased,
and the client will be at risk for bleeding tendencies;
oral hygiene will have to be provided by using a warm saline gargle
instead of brushing the teeth and gums.
4. "I must report a temperature of 1000 E"
The client will be at risk for infection owing to the decrease in WBC production and should report a temperature of l000F (37.8'C) or higher.
70. A 60-year-old client with acute myeloid leukemia (AML) states that he overheard one of the other patients say that AML had a very poor prognosis.
The client explains to the nurse that he had understood his doctor to say
that he had a relatively good prognosis. What is the nurse's best response?
1. "You must have misunderstood. Whom did you hear that from?"
Stating that the client misunderstood is inappropriate for an advocate
of the client and serves no useful purpose.
2. ''AML does have a very poor prognosis for poorly differentiated cells."
3. "AML is the most common nonlymphocytic leukemia."
The statements are true but do not address this client's individual concern.
4. "Your doctor stated your prognosis based on the differentiation of your cells."
The statement, "Your doctor stated your prognosis based on the differentiation of your cells" addresses the client's situation on an individual basis.
The nurse is clarifying that clients have different prognoses-even though they may the same type of leukemia-because of the cell differentiation.
71. The goal of nursing care for a client with acute myeloid leukemia is to prevent
1. cardiac arrhythmias.
Cardiac arrhythmias rarely occur as a result of AML.
2. liver failure.
3. renal failure.
Liver or renal failure may occur, but neither is a major cause of death in AML.
4. hemorrhage.
Bleeding and infection are the major complications and causes of death for clients with AML. Bleeding is related to the degree of thrombocytopenia, and infection is related to the degree of neutropenia.
72. Which of the following does the nurse observe in the client with chronic myeloid leukemia (CML)?
1. Lymphadenopathy.
Lymphadenopathy is rare in CML.
2. Hyperplasia of the gum.
3. Bone pain from expansion of marrow.
Hyperplasia of the gum and bone pain are clinical manifestations of AML.
4. Shortness of breath or slight confusion.
Although the clinical manifestations of CML vary,
clients usually have confusion and shortness of breath related
to decreased capillary perfusion to the brain and lungs.
73. What is the peak age range for acquiring acute lymphocytic leukemia (ALL)?
1. 4 to 12 years.
The peak incidence of ALL is at 4 years of age.
ALL is uncommon after 15 years of age.
2. 20 to 30 years.
3. 40 to 50 years.
The median age at incidence of CML is 40 to 50 years.
The peak incidence of AML occurs at 60 years of age.
4. 60 to 70 years.
Two thirds of cases of chronic lymphocytic leukemia (CLL)
occur in clients older than 60 years of age.
74. The client with ALL develops nausea and a headache.
These clinical manifestations may indicate all of the following except
1. gastric distention.
ALL does not cause gastric distention.
2. meningeal irritation.
ALL does invade the central nervous system,
and clients experience headaches and vomiting from meningeal irritation.
3. chemotherapy side
Clients with ALL receive chemotherapy,
which may also cause nausea and vomiting.
4. effects of radiation
75. In assessing a client in the early stage of chronic lymphocytic leukemia (CLL),
the nurse is aware that the client is prone to experiencing which of the following?
1. Enlarged, painless lymph nodes.
Enlarged painless lymph nodes
are a clinical manifestation of Hodgkin's lymphoma.
2. Headache.
A headache would not be one of the early signs and symptoms expected in CLL because CLL does not cross the blood-brain barrier
and would not irritate the meninges.
3. Hyperplasia of the gums.
Hyperplasia of the gums is a clinical manifestation of AML.
4. Unintentional weight loss.
Clients with CLL develop unintentional weight loss; fever and drenching night sweats; enlarged, painful lymph nodes, spleen, and liver; decreased reaction to skin sensitivity tests (anergy); and susceptibility to viral infections.
76. Which does the nurse suggest as the most appropriate intervention to manage mucositis for a client with acute leukemia?
1. "After each meal or every 4 hours while awake, use lemon-glycerin swabs."
2. "After each meal or every 4 hours while awake, use a commercial mouthwash."
Commercial mouthwashes and lemon-glycerin swabs contain glycerin
and alcohol, which are drying to the mucosa and should be avoided.
3. "After each meal or every 4 hours while awake, use a saline or baking soda solution."
Simple rinses with saline or baking soda solution
are effective and moisten the oral mucosa.
4. "After each meal or every 4 hours while awake, use your own toothpaste and brush."
Brushing after each meal is recommended, but every 4 hours may be too traumatic. During acute leukemia, the neutrophil and platelet counts
are often low and a soft-bristle toothbrush, instead of the client's usual brush,
should be used to prevent bleeding gums.
77. The client with acute leukemia and the health care team
establish mutual client outcomes of improved tidal volume and activity tolerance.
Which measure would be least likely to promote outcome achievement?
1. Ambulating in the hallway.
Ambulating in the hall (using a HEPA filter mask if neutropenic)
is a sensible activity and helps improve conditioning.
2. Sitting up in a chair.
Sitting up in a chair facilitates lung expansion.
3. Lying in bed and taking deep breaths.
The client with acute leukemia experiences fatigue and deconditioning.
Lying in bed and taking deep breaths will not help achieve the goals.
The client must get out of bed to increase activity tolerance
and improve tidal volume.
4. Using a stationary bicycle in the room.
Using a stationary bicycle in the room allows the client
to increase activity as tolerated.
78. The nurse is evaluating the client's learning about combination chemotherapy. Which of the following statements about reasons for using combination chemotherapy indicates the need for further explanation?
1. "Combination chemotherapy is used to interrupt cell growth cycle at different points."
2. "Combination chemotherapy is used to destroy cancer cells and treat side effects simultaneously.
Combination chemotherapy does not mean two groups of drugs, one to kill the cancer cells and one to treat the side effects of the chemotherapy.
3. "Combination chemotherapy is used to decrease resistance."
4. "Combination chemotherapy is used to minimize the toxicity from using high doses of a single agent."
Combination chemotherapy means that multiple drugs are given
to interrupt the cell growth cycle at different points,
to decrease resistance to a chemotherapy agent,
and to minimize the toxicity associated with use of a high dose of a single agent (ie, by using multiple agents with different toxicities).
79. In providing care to the client with leukemia who has developed thrombocytopenia, the nurse assesses the most common sites for bleeding.
Which of the following is not a common site?
1. Biliary system.
The biliary system is not especially prone to hemorrhage.
2. Gastrointestinal tract.
3. Brain and meninges.
4. Pulmonary system effects.
Thrombocytopenia (a low platelet count) leaves the client
at risk for a potentially life-threatening spontaneous hemorrhage
in the gastrointestinal, respiratory, and intracranial cavities.
80. The nurse's best explanation for why the severely neutropenic client is placed in reverse isolation is that reverse isolation helps prevent the spread of organisms
1. to the client from sources outside the client's environment.
The primary purpose of reverse isolation is to reduce transmission of organisms to the client from sources outside the client's environment.
2. from the client to health care personnel, visitors, and other clients.
3. by using special techniques to dispose of contaminated materials.
4. by using special techniques to handle the client's linens and personal items.
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