University of Hawaii Kauai Community College School of Nursing Exam 4 (Hematology and Immunology) Name: __________________________________ Score: __________________________________

Always read the questions carefully. Underline the key information in the question. If there are options, read all the options carefully. If the questions or options have numbers, dates or key words, say them to yourself. This will help you think about the way they sound. Think critically as if you are the nurse in the scenarios and questions. This is a good practice for your next examination. GOOD LUCK. CHEATING IS NOT APPLICABLE WITH THIS EXAM. prepared by: Jeffrey B. Viernes-

1. The nurse is preparing to teach a client with microcytic hypochromic anemia about the diet to follow after discharge. Which of the following foods should be included in the diet? a. Eggs b. Lettuce c. Citrus fruits d. Cheese 2. The nurse would instruct the client to eat which of the following foods to obtain the best supply of vitamin B12? a. Whole grains b. Green leafy vegetables c. Meats and dairy products d. Broccoli and Brussels sprouts 3. The nurse has just admitted a 35-year-old female client who has a serum B12 concentration of 800 pg/ml. Which of the following laboratory findings would cue the nurse to focus the client history on specific drug or alcohol abuse? a. Total bilirubin, 0.3 mg/dL b. Serum creatinine, 0.5 mg/dL c. Hemoglobin, 16 g/dL d. Folate, 1.5 ng/mL 4. The nurse understands that the client with pernicious anemia will have which distinguishing laboratory findings?

a. Schillings test, elevated b. Intrinsic factor, absent. c. Sedimentation rate, 16 mm/hour d. RBCs 5.0 million 5. The nurse devises a teaching plan for the patient with aplastic anemia. Which of the following is the most important concept to teach for health maintenance? a. Eat animal protein and dark leafy vegetables each day b. Avoid exposure to others with acute infection c. Practice yoga and meditation to decrease stress and anxiety d. Get 8 hours of sleep at night and take naps during the day 6. A client comes into the health clinic 3 years after undergoing a resection of the terminal ileum complaining of weakness, shortness of breath, and a sore tongue. Which client statement indicates a need for intervention and client teaching? a. I have been drinking plenty of fluids. b. I have been gargling with warm salt water for my sore tongue. c. I have 3 to 4 loose stools per day. d. I take a vitamin B12 tablet every day. 7. A vegetarian client was referred to a dietician for nutritional counseling for anemia. Which client outcome indicates that the client does not understand nutritional counseling? The client: a. Adds dried fruit to cereal and baked goods b. Cooks tomato-based foods in iron pots c. Drinks coffee or tea with meals d. Adds vitamin C to all meals 8. A client was admitted with iron deficiency anemia and blood-streaked emesis. Which question is most appropriate for the nurse to ask in determining the extent of the clients activity intolerance? a. What activities were you able to do 6 months ago compared with the present? b. How long have you had this problem? c. Have you been able to keep up with all your usual activities? d. Are you more tired now than you used to be? 9. The primary purpose of the Schilling test is to measure the clients ability to: a. Store vitamin B12 b. Digest vitamin B12 c. Absorb vitamin B12 d. Produce vitamin B12

10. The nurse implements which of the following for the client who is starting a Schilling test? a. Administering methylcellulose (Citrucel) b. Starting a 24- to 48 hour urine specimen collection c. Maintaining NPO status d. Starting a 72 hour stool specimen collection 11. A client with pernicious anemia asks why she must take vitamin B12 injections for the rest of her life. What is the nurses best response? a. The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient acid. b. The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient intrinsic factor. c. The reason for your vitamin deficiency is an excessive excretion of the vitamin because of kidney dysfunction. d. The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production. 12. The nurse is assessing a clients activity intolerance by having the client walk on a treadmill for 5 minutes. Which of the following indicates an abnormal response? a. Pulse rate increased by 20 bpm immediately after the activity b. Respiratory rate decreased by 5 breaths/minute c. Diastolic blood pressure increased by 7 mm Hg d. Pulse rate within 6 bpm of resting phase after 3 minutes of rest. 13. When comparing the hematocrit levels of a post-op client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC and hemoglobin values remained stable at 4.5 million and 11.9 g/dL, respectively. Which nursing intervention is most appropriate? a. Check the dressing and drains for frank bleeding b. Call the physician c. Continue to monitor vital signs d. Start oxygen at 2L/min per NC 14. A client is to receive epoetin (Epogen) injections. What laboratory value should the nurse assess before giving the injection? a. Hematocrit b. Partial thromboplastin time c. Hemoglobin concentration d. Prothrombin time 15. A client states that she is afraid of receiving vitamin B12 injections because of

the potential toxic reactions. What is the nurses best response to relieve these fears? a. Vitamin B12 will cause ringing in the eats before a toxic level is reached. b. Vitamin B12 may cause a very mild skin rash initially. c. Vitamin B12 may cause mild nausea but nothing toxic. d. Vitamin B12 is generally free of toxicity because it is water soluble. 16. A client with microcytic anemia is having trouble selecting food items from the hospital menu. Which food is best for the nurse to suggest for satisfying the clients nutritional needs and personal preferences? a. Egg yolks b. Brown rice c. Vegetables d. Tea 17. A client with macrocytic anemia has a burn on her foot and states that she had been watching television while lying on a heating pad. What is the nurses first response? a. Assess for potential abuse b. Check for diminished sensations c. Document the findings d. Clean and dress the area 18. Which of the following nursing assessments is a late symptom of polycythemia vera? a. Headache b. Dizziness c. Pruritus d. Shortness of breath 19. The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the clients teaching plan? Select all that apply. a. Hearing loss b. Visual disturbance c. Headache d. Orthopnea e. Gout f. Weight loss 20. When a client is diagnosed with aplastic anemia, the nurse monitors for changes in which of the following physiological functions? a. Bleeding tendencies

b. Intake and output c. Peripheral sensation d. Bowel function

Answer key: 1. ANSWER A. One of the microcytic, hypochromic anemias is iron-deficiency amenia. A rich source of iron is needed in the diet, and eggs are high in iron. Other foods high in iron include organ and muscle (dark) meats; shellfish, shrimp, and tuna; enriched, wholegrain, and fortified cereals and breads; legumes, nuts, dried fruits, and beans; oatmeal; and sweet potatoes. Dark green leafy vegetables and citrus fruits are good sources of vitamin C. Cheese is a good source of calcium. 2. ANSWER C. Good sources of vitamin B12 include meats and dairy products. Whole grains are a good source of thiamine. Green leafy vegetables are good sources of niacin, folate, and carotenoids (precursors of vitamin A). Broccoli and Brussels sprouts are good sources of ascorbic acid (vitamin C). 3. ANSWER D. The normal range of folic acid is 1.8 to 9 ng/mL, and the normal range of vitamin B12 is 200 to 900 pg/mL. A low folic acid level in the presence of a normal vitamin B12 level is indicative of a primary folic acid-deficiency anemia. Factors that affect the absorption of folic acid are drugs such as methotrexate, oral contraceptives, antiseizure drugs, and alcohol. The total bilirubin, serum creatinine, and hemoglobin values are within normal limits. 4. ANSWER B. The defining characteristic of pernicious anemia, a megaloblastic anemia, is lack of the intrinsic factor, which results from atrophy of the stomach wall. Without the intrinsic factor, vitamin B12 cannot be absorbed in the small intestines, and folic acid needs vitamin B12 for DNA synthesis of RBCs. The gastric analysis was done to determine the primary cause of the anemia. An elevated excretion of the injected radioactive vitamin B12, which is protocol for the first and second stage of the Schilling test, indicates that the client has the intrinsic factor and can absorb vitamin B12 into the intestinal tract. A sedimentation rate of 16 mm/hour is normal for both men and women and is a nonspecific test to detect the presence of inflammation. It is not specific to anemias. An RBC value of 5.0 million is a normal value for both men and women and does not indicate anemia. 5. ANSWER B. Clients with aplastic anemia are severely immunocompromised and at risk for infection and possible death related to bone marrow suppression and pancytopenia. Strict aseptic technique and reverse isolation are important measures to prevent infection. Although diet, reduced stress, and rest are valued in supporting health, the potentially fatal consequence of an acute infection places it as a priority for teaching the client about health maintenance. Animal meat and dark green leafy vegetables, good sources of vitamin B12 and folic acid, should be included in the daily diet. Yoga and meditation are good complimentary therapies to reduce stress. Eight hours of rest and naps are good for spacing and pacing activity and rest. 6. ANSWER D. Vitamin B12 combines with intrinsic factor in the stomach and is then carried to the ileum, where it is absorbed in the bloodstream. In this situation, vitamin B12 cannot be absorbed regardless of the amount of oral intake of sources of vitamin B12 such as animal protein or vitamin B12 tablets. Vitamin B12 needw to be injected every month, because the ileum has been surgically removed. Replacement of fluids and electrolytes is important when the client has continuous multiple loose stools on a daily basis. Warm salt water is used to soothe sore mucous membranes. Crohns disease and small bowel resection may cause several loose stools a day.

7. ANSWER C. Coffee and tea increase gastrointestinal mobility and inhibit the absorption of nonheme iron. Clients are instructed to add dried fruits to dishes at every meal because dried fruits are a nonheme or nonanimal iron source. Cooking in iron cookware, especially acid-based foods such as tomatoes, adds iron to the diet. Clients are instructed to add a rich supply of vitamin C to every meal because the absorption of iron is increased when food with vitamin C or ascorbic acid is consumed. 8. ANSWER A. It is difficult to determine activity intolerance without objectively comparing activities from one time frame to another. Because iron deficiency anemia can occur gradually and individual endurance varies, the nurse can best assess the clients activity tolerance by asking the client to compare activities 6 months ago and at the present. Asking a client how long a problem has existed is a very open-ended question that allows for too much subjectivity for any definition of the clients activity tolerance. Also, the client may not even identify that a problem exists. Asking the client whether he is staying abreast of usual activities addresses whether the tasks were completed, not the tolerance of the client while the tasks were being completed or the resulting condition of the client after the tasks were completed. Asking the client if he is more tired now than usual does not address his activity tolerance. Tiredness is a subjective evaluation and again can be distorted by factors such as the gradual onset of the anemia or the endurance of the individual. 9. ANSWER C. Pernicious anemia is caused by the bodys inability to absorb vitamin B12. This results in a lack of intrinsic factor in the gastric juices. Schillings test helps diagnose pernicious anemia by determining the clients ability to absorb vitamin B12. 10. ANSWER B. Urinary vitamin B12 levels are measured after the ingestion of radioactive vitamin B12. A 24-to 48- hour urine specimen is collected after administration of an oral dose of radioactively tagged vitamin B12 and an injection of nonradioactive vitamin B12. In a healthy state of absorption, excess vitamin B12 is excreted in the urine; in a malabsorption state or when the intrinsic factor is missing, vitamin B12 is excreted in the feces. Citrucel is a bulk-forming agent. Laxatives interfere with the absorption of vitamin B12. The client is NPO 8 to 12 hours before the test but is not NPO during the test. A stool collection is not part of the Schilling test. If stool contaminates the urine collection, the results will be altered. 11. ANSWER B. Most clients with pernicious anemia have deficient production of intrinsic factor in the stomach. Intrinsic factor attaches to the vitamin in the stomach and forms a complex that allows the vitamin to be absorbed in the small intestine. The stomach is producing enough acid, there is not an excessive excretion of the vitamin, and there is not a rapid production of RBCs in this condition. 12. ANSWER B. The normal physiologic response to activity is an increased metabolic rate over the resting basal rate. The decrease in respiratory rate indicates that the client is not strong enough to complete the mechanical cycle of respiration needed for gas exchange. The postactivity pulse is expected to increase immediately after activity but by no more than 50 bpm if it is strenuous activity. The diastolic blood pressure is expected to rise but by no more than 15 mm Hg. The pulse returns to within 6 bpm of the resting pulse after 3 minutes of rest. 13. ANSWER C. The nurse should continue to monitor the client, because this value reflects a normal physiologic response. The physician does not need to be called, and oxygen does not need to be started based on these laboratory findings. Immediately after

surgery, the clients hematocrit reflects a falsely high value related to the bodys compensatory response to the stress of sudden loss of fluids and blood. Activation of the intrinsic pathway and the renin-angiotensin cycle via antidiuretic hormone produces vasoconstriction and retention of fluid for the first 1 to 2 day post-op. By the second to third day, this response decreases and the clients hematocrit level is more reflective of the amount of RBCs in the plasma. Fresh bleeding is a less likely occurrence on the third post-op day but is not impossible; however, the nurse would have expected to see a decrease in the RBC and hemoglobin values accompanying the hematocrit. 14. ANSWER A. Epogen is a recombinant DNA form of erythropoietin, which stimulates the production of RBCs and therefore causes the hematocrit to rise. The elevation in hematocrit causes an elevation in blood pressure; therefore, the blood pressure is a vital sign that should be checked. The PTT, hemoglobin level, and PT are not monitored for this drug. 15. ANSWER D. Vitamin B12 is a water-soluble vitamin. When water-soluble vitamins are taken in excess of the bodys needs, they are filtered through the kidneys and excreted. Vitamin B12 is considered to be nontoxic. Adverse reactions that have occurred are believed to be related to impurities or to the preservative in B12 preparations. Ringing in the ears, skin rash, and nausea are not considered to be related to vitamin B12 administration. 16. ANSWER B. Brown rice is a source of iron from plant sources (nonheme iron). Other sources of nonheme iron are whole-grain cereals and breads, dark green vegetables, legumes, nuts, dried fruits (apricots, raisins, dates), oatmeal, and sweet potatoes. Egg yolks have iron but it is not as well absorbed as iron from other sources. Vegetables are a good source of vitamins that may facilitate iron absorption. Tea contains tannin, which combines with nonheme iron, preventing its absorption. 17. ANSWER B. Macrocytic anemias can result from deficiencies in vitamin B12 or ascorbic acid. Only vitamin B12 deficiency causes diminished sensations of peripheral nerve endings. The nurse should assess for peripheral neuropathy and instruct the client in self-care activities for her diminished sensation to heat and pain. The burn could be related to abuse, but this conclusion would require more supporting data. The findings should be documented, but the nurse would want to address the clients sensations first. The decision of how to treat the burn should be determined by the physician. 18. ANSWER C. Pruritus is a late symptom that results from abnormal histamine metabolism. Headache and dizziness are early symptoms from engorged veins. Shortness of breath is an early symptom from congested mucous membrane and ineffective gas exchange. 19. ANSWERS B, C, D and E. Polycythemia vera, a condition in which too many RBCs are produced in the blood serum, can lead to an increase in the hematocrit and hypervolemia, hyperviscosity, and hypertension. Subsequently, the client can experience dizziness, tinnitus, visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symptoms such as heart failure (shortness of breath and orthopnea) and increased clotting time or symptoms of an increased uric acid level such as painful swollen joints (usually the big toe). Hearing loss and weight loss are not manifestations associated with polycythemia vera. 20. ANSWER A. Aplastic anemia decreases the bone marrow production of RBCs, WBCs, and platelets. The client is at risk for bruising and bleeding tendencies. A change

in the intake and output is important, but assessment for the potential for bleeding takes priority. Change in the peripheral nervous system is a priority problem specific to clients with vitamin B12 deficiency. Change in bowel function is not associated with aplastic anemia.