HESI Med Surg Hematological

Correct Answer: Fragile tissues and altered clotting mechanisms may result in hemorrhage.

Explanation:

Leukemia is associated with bone marrow suppression, leading to decreased production of platelets and clotting factors. This results in increased fragility of blood vessels and tissues, making bleeding more likely even from minor trauma. Using an electric razor reduces the risk of cuts or nicks, which could lead to excessive bleeding due to these impaired clotting mechanisms.

Why the Other Options Are Incorrect:

Trauma and microabrasions may contribute to anemia.

While trauma can worsen anemia in some cases, the primary issue with using a razor is the risk of bleeding, not trauma or microabrasions leading directly to anemia. Anemia in leukemia patients results from decreased production of red blood cells due to the disease itself, not from trauma.

The client is at risk for spontaneous and uncontrolled bleeding.

This is true for patients with leukemia due to low platelet counts, but the focus of the electric razor recommendation is to prevent cuts or abrasions, not to directly address the issue of spontaneous bleeding. The goal is to minimize trauma that could trigger bleeding.

The client is at risk for infection from microorganisms.

While leukemia patients are immunocompromised and at risk for infections, the recommendation to use an electric razor is primarily aimed at preventing bleeding from cuts. Infection prevention would involve other measures, such as hand hygiene and avoiding exposure to pathogens, but the electric razor recommendation specifically addresses the risk of bleeding.

Summary:

Fragile tissues and altered clotting mechanisms may result in hemorrhage. The primary concern for leukemia patients is avoiding cuts that could lead to bleeding due to impaired clotting ability. The electric razor minimizes this risk.

Correct answer: A. 3.6 and 5.4 million/mm³

Explanation:

The normal range of erythrocytes (red blood cells) for adults typically falls between approximately 3.6 and 5.4 million/mm³. This range can vary slightly depending on the laboratory standards, gender, and environmental factors like altitude, but generally, adult females have counts closer to 3.6–5.0 million/mm³ and males 4.2–5.4 million/mm³. The primary role of erythrocytes is to carry oxygen from the lungs to the body tissues and assist in returning carbon dioxide to the lungs for exhalation.

Why the Other Options Are Incorrect:

B. 5.6 and 8.4 million/mm³.

This range is too high for the normal adult erythrocyte count. Values in this range might suggest polycythemia or may be seen at very high altitudes but are not standard for the general adult population.

C. 7.2 and 9.3 million/mm³.

This is also an abnormally high range and does not reflect the normal erythrocyte count for adults. Such levels would be pathologic in most circumstances.

D. 8.2 and 10.7 million/mm³.

This option reflects an extremely elevated erythrocyte count, far above normal limits, which would indicate a serious pathological condition if ever seen in an adult.

Summary:

The correct answer is A. 3.6 and 5.4 million/mm³, which reflects the normal range of erythrocytes in adults. The other options provide values that are significantly above the normal range and would not be considered typical for a healthy adult.

Correct Answer: The manufacture and development of blood cells

Explanation:

Hematopoiesis is the process by which blood cells are produced and developed. This includes the formation of red blood cells (erythrocytes), white blood cells (leukocytes), and platelets (thrombocytes), which all originate from hematopoietic stem cells in the bone marrow. The process is essential for maintaining the balance of blood cells in the body.

Why the Other Options Are Incorrect:

The production of lymphatic fluid in the body

This refers to the process involved in lymph formation and circulation, not hematopoiesis. Lymph is produced by the lymphatic system, not by the bone marrow or the hematopoietic process.

The making of red blood cells and lymph

Hematopoiesis is concerned with the creation of blood cells, not lymph. While red blood cells are part of hematopoiesis, lymph production occurs separately in the lymphatic system.

The development of lymph in the bone marrow

Lymph development is not a function of the bone marrow. Lymph is produced by the lymphatic system, primarily from tissues such as lymph nodes, not as part of hematopoiesis.

Summary:

The manufacture and development of blood cells, which is the definition of hematopoiesis. The other options refer to processes outside the scope of hematopoiesis, such as lymph production and development.

Correct Answer: blast cells in the periphery means there is no more room for them in the bone marrow because the cancer cells are taking up all of the space 

Blast cells are immature cells that are typically found in the bone marrow, where they are supposed to mature into fully functional blood cells. In leukemia, the bone marrow becomes infiltrated with abnormal blast cells that do not mature properly. As a result, the number of these cells increases and can spill into the peripheral blood, where they are not usually present in large numbers. The presence of blast cells in the peripheral blood indicates that the bone marrow is overwhelmed, and the body is unable to keep up with the production of normal, mature blood cells due to the overproduction of leukemia cells. This is a key diagnostic sign of leukemia and helps distinguish it from other conditions.

Why the Other Options Are Incorrect:

Blast cells are always present in the periphery

This is incorrect. Normally, blast cells are not found in the peripheral blood in healthy individuals. They should only be present in the bone marrow, where they mature into red blood cells, white blood cells, or platelets.

Blast cells are never in the periphery

This is also incorrect. Under normal circumstances, blast cells do not appear in the peripheral blood, but in the case of leukemia, they do spill over into the blood due to the overwhelmed bone marrow.

Blast cells are added up with RBCs to determine the type of cancer

This is incorrect. Blast cells are not added to RBCs to determine the type of cancer. Instead, the presence of blast cells in the peripheral blood is used to help diagnose leukemia and assess the degree of disease involvement.

Summary:

The presence of blast cells in the periphery is a key indicator that the bone marrow is being overrun by cancerous cells, which is why b.) blast cells in the periphery means there is no more room for them in the bone marrow because the cancer cells are taking up all of the space is the correct answer.

Correct Answer: Blood loss from the gastrointestinal or genitourinary tract

Explanation of the Correct Answer:

In older adults, the most common causes of anemia are often related to chronic blood loss, particularly from the gastrointestinal or genitourinary tract. Conditions like gastrointestinal bleeding, ulcers, or cancers (such as colorectal cancer) are more common in the elderly and can lead to gradual, chronic blood loss, contributing to anemia. It’s essential to assess for potential sources of occult blood loss in these areas.

Explanation of Incorrect Answers:

Excessive consumption of coffee or tea

While coffee and tea can inhibit the absorption of iron, this is not typically the primary cause of anemia in the elderly. Chronic blood loss or a decrease in iron stores are more significant contributors.

Elimination of iron by the body

While the body does eliminate some iron, this is not a major factor in causing anemia in the elderly. The main issue for anemia in older adults is more likely related to insufficient iron absorption or blood loss rather than excessive elimination.

Decrease in the total body iron stores with age

Although a decrease in iron stores can occur with aging, blood loss from the gastrointestinal or genitourinary tract is more commonly the culprit for anemia in older individuals. Chronic blood loss can deplete iron stores more significantly.

Summary:

The most likely cause of anemia in an 87-year-old female is Blood loss from the gastrointestinal or genitourinary tract, which is a common issue in older adults due to conditions like ulcers, gastrointestinal bleeding, or cancers.

Correct Answer: D. Use soft small toothbrush for mouth care

Explanation:

A platelet count of 20,000/µL is critically low (normal range: 150,000–400,000/µL) and places the patient at high risk for bleeding. Chemotherapy commonly causes thrombocytopenia, or low platelet count, due to its suppressive effects on bone marrow. At this level, even minor trauma can result in significant bleeding.

One essential nursing intervention is to implement bleeding precautions. This includes using a soft-bristled or small toothbrush to minimize the risk of gum injury and oral bleeding during mouth care. Other bleeding precautions might include avoiding invasive procedures, using electric razors, and monitoring for bruising or petechiae.

Why the Other Options Are Incorrect:

Monitor closely for signs of infection

While this is important in leukemic patients, especially due to low white blood cell counts, a low platelet count specifically increases bleeding risk, not infection. Thus, this is not the priority intervention tied directly to the lab result.

Monitor the temperature every 4 hours

This intervention relates to febrile neutropenia, not thrombocytopenia. It’s an important general measure in cancer care, but not the most relevant for a platelet count of 20,000/µL.

Initiate protective isolation precautions

Protective (reverse) isolation is appropriate for patients with neutropenia (low white blood cell count), not thrombocytopenia. This measure does not address the bleeding risk that comes with low platelets.

Summary:

With a critically low platelet count of 20,000/µL, the focus must be on preventing bleeding. Therefore, using a soft, small toothbrush for mouth care is a direct and appropriate intervention. The correct answer is use soft small toothbrush for mouth care.

Correct Answer: By palpating the abdomen

Explanation:

Enlargement of the liver (hepatomegaly) and spleen (splenomegaly) is a common finding in leukemia due to infiltration of malignant cells into these organs. The best way to assess for enlargement and tenderness of the liver and spleen is through palpation of the abdomen. The nurse can feel for any abnormal enlargements or tenderness in the upper left (spleen) and right (liver) quadrants of the abdomen. This physical examination is essential in identifying potential organ involvement in leukemia.

Why the Other Options Are Incorrect:

By reviewing laboratory test results

While laboratory tests can provide helpful information, such as abnormal liver function tests or markers for infection or leukemia, they do not directly assess for physical changes like enlargement or tenderness of the liver and spleen. Palpation is necessary to physically detect these signs.

By calculating the absolute neutrophil count

The absolute neutrophil count (ANC) is important in evaluating the immune status of a client with leukemia, particularly in assessing the risk of infection, but it does not assess organ size or tenderness. ANC provides insight into the number of mature neutrophils but does not directly relate to the physical examination of the liver and spleen.

By looking for evidence of bruising

Bruising is a common sign of thrombocytopenia in leukemia, but it does not provide information about liver or spleen enlargement. Bruising relates to platelet dysfunction, which is different from the physical assessment for hepatomegaly or splenomegaly.

Summary:

The Oncology APN should use abdominal palpation to assess for the enlargement and tenderness of the liver and spleen, which may indicate organ involvement in leukemia. Other methods like lab tests or calculating the ANC are helpful for other aspects of leukemia management but do not directly assess organ size.

Correct Answer: Transportation of O2 to the tissues and removal of CO2 from the tissues

Explanation:

The primary function of erythrocytes (red blood cells) is to transport oxygen (O2) from the lungs to the tissues and organs throughout the body and to carry carbon dioxide (CO2) from the tissues back to the lungs for exhalation. This is achieved through the binding of O2 and CO2 to hemoglobin molecules within the erythrocytes.

Why the Other Options Are Incorrect:

Act as mediators for the immune system

This function is primarily carried out by white blood cells (leukocytes), not erythrocytes. Leukocytes are responsible for immune response and mediating defense mechanisms against pathogens.

Destroy invading organisms

This function is also carried out by white blood cells, particularly neutrophils, macrophages, and lymphocytes, which are involved in phagocytosis and immune defense against invading organisms. Erythrocytes do not play a direct role in destroying pathogens.

Oxygenation of the brain

While erythrocytes are responsible for transporting oxygen to all tissues and organs, including the brain, the term "oxygenation of the brain" is too specific and does not reflect the general role of erythrocytes, which is to deliver oxygen to all cells in the body, not just the brain.

Summary:

Erythrocytes are primarily responsible for transporting oxygen and carbon dioxide throughout the body. The other options describe functions of white blood cells or are not accurate descriptions of erythrocyte functions.

Correct Answer: Avoid any activity that makes you short of breath.

Explanation:

In sickle cell anemia, physical stress and low oxygen levels can trigger a sickle cell crisis. Activities that lead to shortness of breath can cause the blood to become less oxygenated, which may promote sickling of the red blood cells and block blood flow, leading to pain and other complications. Therefore, avoiding activities that make the patient short of breath is an effective preventative strategy for reducing the risk of a crisis.

Why the other options are incorrect:

Avoid any sports that tire you out:

While avoiding overexertion is important, some physical activity is generally encouraged in children with sickle cell anemia, as long as they are adequately hydrated and do not overstrain themselves. It is not necessary to avoid sports altogether unless it leads to exhaustion or triggers a crisis.

Drink at least 8 glasses of water every day:

While hydration is indeed crucial in sickle cell anemia to help prevent sickling of the cells, it is not the most effective preventative measure on its own when compared to avoiding strenuous activities that can lead to hypoxia (low oxygen levels) or shortness of breath. Hydration should definitely be part of the overall management, but the primary concern for preventing crises is avoiding situations that lower oxygen levels in the blood.

Stay on oxygen therapy 24/7:

Continuous oxygen therapy is typically not required unless there is a specific clinical indication, such as during a crisis or if the patient has low oxygen levels. Oxygen therapy is not a daily management strategy for most individuals with sickle cell anemia. Instead, maintaining overall health and preventing physical stressors, like avoiding activities that induce shortness of breath, is more critical.

Summary:

The most important recommendation for preventing a sickle cell crisis is to avoid activities that make the child short of breath, as low oxygen levels can contribute to the sickling of red blood cells and trigger a crisis.