NURS 432 Hematologic Review questions with
accurate answers
A client asks about the process of graft-versus-host disease. What
explanation by the nurse is correct?
a. Because of immunosuppression, the donor cells may take over
b. It's like a transfusion reaction because no perfect matches exist
c. The patient's cells are fighting donor cells for dominance
d. The donor's cells are actually attacking the patient's cells Ans✓✓✓ D.
The donor's cells are actually attacking the patient's cells
Graft-versus-host disease is an autoimmune-type process in which the
donor cells recognize the client's cells as foreign and begin attacking
them. The other answers are not accurate.
A client has a leg wound that is in Stage II of the inflammatory response.
For what sign or
symptom does the nurse assess?
a. Noticeable rubor
b. Purulent drainage
c. Swelling and pain
d. Warmth at the site Ans✓✓✓ ANS: B
During the second phase of the inflammatory response, neutrophilia
occurs, producing pus.
Rubor (redness), swelling, pain, and warmth are cardinal signs of the
general inflammatory
,process.
A client has a platelet count of 9000/mm3. The nurse finds the client
confused and mumbling. What nursing action takes PRIORITY at this
time?
a. Call the Rapid Response Team
b. Take a set of vital signs
c. Institute bleeding precautions
d. Place the client on bedrest Ans✓✓✓ A. Call the Rapid Response
Team
With a platelet count this low, the client is at high risk of spontaneous
bleeding. The most disastrous complication would be intracranial
bleeding. The nurse needs to call the Rapid Response Team as this client
has manifestations of a sudden neurologic change. Bleeding precautions
will not address the immediate situation. Placing the client on bedrest is
important, but the critical action is to call for immediate medical
attention.
A client has been admitted after sustaining a humerus fracture that
occurred when picking up the family cat. What test result would the
nurse correlate to this condition?
a. Bence-Jones protein in urine
b. Epstein-Barr virus: positive
c. Hemoglobin: 18 mg/dL
d. Red blood cell count: 8.2 million/mcL Ans✓✓✓ A. Bence-Jones
protein in urine
,This client has possible multiple myeloma. A positive Bence-Jones
protein finding would correlate with this condition. The Epstein-Barr
virus is a herpesvirus that causes infectious mononucleosis and some
cancers. A hemoglobin of 18 mg/dL is slightly high for a male and
somewhat high for a female; this can be cause by several conditions, and
further information would be needed to correlate this value with a
specific medical condition. A red blood cell count of 8.2 million/mcL is
also high, but again, more information would be needed to correlate this
finding with a specific medical condition.
A client has received a bone marrow transplant and is waiting for
engraftment. What action(s) by the nurse are MOST APPROPRIATE?
(SATA)
a. Not allowing any visitors until engraftment
b. Limiting the protein in the client's diet
c. Placing the client in protective precautions
d. Teaching visitors appropriate hand hygiene
e. Telling visitors not to bring live flowers or plants Ans✓✓✓ C, D, E
The client waiting for engraftment after bone marrow transplant has no
white cells to protect him or her against infection. The client is on
protective precautions and visitors are taught hand hygiene. No fresh
flowers or plants are allowed due to the standing water in the vase or
container that may harbor organisms; clients are also told not to work
with houseplants in the home. Limiting protein is not a healthy option
and will not promote engraftment.
, A client has thrombocytopenia. What statement indicates that the client
understands self-management of this condition?
a. I brush and use dental floss every day
b. I chew hard candy for my dry mouth
c. I usually put ice on bumps or bruises
d. Nonslip socks are best when I walk Ans✓✓✓ C. I usually put ice on
bumps or bruises
The client should be taught to apply ice to areas of minor trauma.
Flossing is not recommended. Hard foods should be avoided. The client
should wear well-fitting shoes when ambulating.
A client in sickle cell crisis is dehydrated and in the emergency
department. The nurse plans to start an IV. Which fluid choice is best?
a. 0.45% normal saline
b. 0.9% normal saline
c. Dextrose 50% (D50)
d. Lactated Ringer's solution Ans✓✓✓ A. 0.45% normal saline
Because clients in sickle cell crisis are often dehydrated, the fluid of
choice is a hypotonic solution such as 0.45% normal saline. 0.9% NS
and LR's solution are isotonic. D50 is hypertonic and not used for
hydration.
A client is having a bone marrow aspiration and biopsy and is extremely
anxious. What action by the nurse is the most appropriate?
accurate answers
A client asks about the process of graft-versus-host disease. What
explanation by the nurse is correct?
a. Because of immunosuppression, the donor cells may take over
b. It's like a transfusion reaction because no perfect matches exist
c. The patient's cells are fighting donor cells for dominance
d. The donor's cells are actually attacking the patient's cells Ans✓✓✓ D.
The donor's cells are actually attacking the patient's cells
Graft-versus-host disease is an autoimmune-type process in which the
donor cells recognize the client's cells as foreign and begin attacking
them. The other answers are not accurate.
A client has a leg wound that is in Stage II of the inflammatory response.
For what sign or
symptom does the nurse assess?
a. Noticeable rubor
b. Purulent drainage
c. Swelling and pain
d. Warmth at the site Ans✓✓✓ ANS: B
During the second phase of the inflammatory response, neutrophilia
occurs, producing pus.
Rubor (redness), swelling, pain, and warmth are cardinal signs of the
general inflammatory
,process.
A client has a platelet count of 9000/mm3. The nurse finds the client
confused and mumbling. What nursing action takes PRIORITY at this
time?
a. Call the Rapid Response Team
b. Take a set of vital signs
c. Institute bleeding precautions
d. Place the client on bedrest Ans✓✓✓ A. Call the Rapid Response
Team
With a platelet count this low, the client is at high risk of spontaneous
bleeding. The most disastrous complication would be intracranial
bleeding. The nurse needs to call the Rapid Response Team as this client
has manifestations of a sudden neurologic change. Bleeding precautions
will not address the immediate situation. Placing the client on bedrest is
important, but the critical action is to call for immediate medical
attention.
A client has been admitted after sustaining a humerus fracture that
occurred when picking up the family cat. What test result would the
nurse correlate to this condition?
a. Bence-Jones protein in urine
b. Epstein-Barr virus: positive
c. Hemoglobin: 18 mg/dL
d. Red blood cell count: 8.2 million/mcL Ans✓✓✓ A. Bence-Jones
protein in urine
,This client has possible multiple myeloma. A positive Bence-Jones
protein finding would correlate with this condition. The Epstein-Barr
virus is a herpesvirus that causes infectious mononucleosis and some
cancers. A hemoglobin of 18 mg/dL is slightly high for a male and
somewhat high for a female; this can be cause by several conditions, and
further information would be needed to correlate this value with a
specific medical condition. A red blood cell count of 8.2 million/mcL is
also high, but again, more information would be needed to correlate this
finding with a specific medical condition.
A client has received a bone marrow transplant and is waiting for
engraftment. What action(s) by the nurse are MOST APPROPRIATE?
(SATA)
a. Not allowing any visitors until engraftment
b. Limiting the protein in the client's diet
c. Placing the client in protective precautions
d. Teaching visitors appropriate hand hygiene
e. Telling visitors not to bring live flowers or plants Ans✓✓✓ C, D, E
The client waiting for engraftment after bone marrow transplant has no
white cells to protect him or her against infection. The client is on
protective precautions and visitors are taught hand hygiene. No fresh
flowers or plants are allowed due to the standing water in the vase or
container that may harbor organisms; clients are also told not to work
with houseplants in the home. Limiting protein is not a healthy option
and will not promote engraftment.
, A client has thrombocytopenia. What statement indicates that the client
understands self-management of this condition?
a. I brush and use dental floss every day
b. I chew hard candy for my dry mouth
c. I usually put ice on bumps or bruises
d. Nonslip socks are best when I walk Ans✓✓✓ C. I usually put ice on
bumps or bruises
The client should be taught to apply ice to areas of minor trauma.
Flossing is not recommended. Hard foods should be avoided. The client
should wear well-fitting shoes when ambulating.
A client in sickle cell crisis is dehydrated and in the emergency
department. The nurse plans to start an IV. Which fluid choice is best?
a. 0.45% normal saline
b. 0.9% normal saline
c. Dextrose 50% (D50)
d. Lactated Ringer's solution Ans✓✓✓ A. 0.45% normal saline
Because clients in sickle cell crisis are often dehydrated, the fluid of
choice is a hypotonic solution such as 0.45% normal saline. 0.9% NS
and LR's solution are isotonic. D50 is hypertonic and not used for
hydration.
A client is having a bone marrow aspiration and biopsy and is extremely
anxious. What action by the nurse is the most appropriate?
