[Osborn] chapter 63

Learning Outcomes [Number and Title ]

Learning Outcome 1
Describe the physiology of hematopoiesis, thrombopoiesis, and
hemostasis.
Learning Outcome 2
Explain the pathophysiological alterations in erythropoiesis,
thrombopoiesis, and hemostasis that give rise to specific
hematologic disorders.
Learning Outcome 3
Compare and contrast the causes, the therapeutic management,
and clinical presentation of the various types of anemias and
hemostasis disorders.
Learning Outcome 4
Analyze laboratory values, correlating to physical signs and
symptoms, and distinguish between various hematologic
disorders.
Learning Outcome 5
Explain appropriate nursing interventions for the management
of thrombocytopenia.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

1. Which of the following statements best describes thrombopoiesis?

1. Platelet development from the hematopoietic stem cell to fully mature platelets
2. Blood cell development, beginning in the bone marrow and extending through cell
maturation in the peripheral bloodstream
3. Response to extrinsic factors that initiates the clotting cascade
4. The process that mitigates blood loss due to injury to any blood vessel
Correct Answer: Platelet development from the hematopoietic stem cell to fully mature platelets
Rationale: Hematopoiesis refers to blood cell development. Thrombopoiesis is not an extrinsic
factor that initiates blood clotting; it does refer to platelet development as only one component of
blood cell development. The process that mitigates blood loss due to injury to any blood vessel is
called hemostasis.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

2. Which of the following disorders is reflective of primary hemostasis?

1.
2.
3.
4.

Thrombocytopenia
Hemophilia
Aplastic anemia
Iron deficiency anemia

Correct Answer: Thrombocytopenia

Rationale: Thrombocytopenia is defined as a decrease in the number of circulating platelets from
the normal value of 150,000/L. Hemophilia is a disorder of secondary hemostasis; it is a chronic
condition that arises from the inheritance of mutated genes that control some of the clotting
factors, VIII or IX. Aplastic anemia is a disorder characterized by severe pancytopenia (low or
absent red blood cells, white blood cells, and platelets) in both the periphery and bone marrow.
Iron deficiency anemia is a common underlying cause of anemia representative of insufficient or
depleted iron supplies.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

3. In instructing clients with disorders related to platelet and clotting factors, the nurse should
advise them to:
Select all that apply.
1.
2.
3.
4.
5.

Refrain from flossing during the acute phase.

Use lightweight blankets.
Avoid Valsalvas maneuver.
Monitor skin condition.
Brush teeth only once per day.

Correct Answer:
1. Refrain from flossing during acute phase.
2. Use lightweight blankets.
3. Avoid Valsalvas maneuver.
4. Monitor skin condition.
Rationale:
Refrain from flossing during acute phase. Flossing may stimulate bleeding.
Use lightweight blankets. Heat causes vasodilation.
Avoid Valsalvas maneuver. Increased intrathoracic pressure may cause bleeding.
Monitor skin condition. Petechiae and ecchymoses are signs of bleeding.
Brush teeth only once per day. The number of times teeth are brushed is irrelevant and does not
precipitate bleeding.
Cognitive Level: Analysis
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

4. A client is admitted with the diagnosis of generalized anemia. This disorder is caused by:
Select all that apply.
1.
2.
3.
4.
5.

A disruption in erythrocyte volume.

Decreased oxygen availability to the tissues.
Defective oxygenation in the lungs.
An airway obstruction.
Abnormal pulmonary function.

Correct Answer:
1. A disruption in erythrocyte volume.
2. Decreased oxygen availability to the tissues.
Rationale:
A disruption in erythrocyte volume. Decreased erythrocyte volume results in anemic hypoxia or
decreased oxygen availability to the tissues specifically due to decreased concentration of
functional hemoglobin or a reduced number of red blood cells.
Decreased oxygen availability to the tissues. Decreased erythrocyte volume results in anemic
hypoxia or decreased oxygen availability to the tissues specifically due to decreased concentration
of functional hemoglobin or a reduced number of red blood cells.
Defective oxygenation in the lungs. Defective oxygenation in the lungs causes hypoxic hypoxia,
in which oxygen deprivation occurs from defective oxygenation in the lungs.
An airway obstruction. An airway obstruction results in defective oxygenation in the lungs.
Abnormal pulmonary function. Abnormal pulmonary function results in defective oxygenation
in the lungs.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

5. Client symptoms associated with thrombocytopenia are centered around:

Select all that apply.
1.
2.
3.
4.
5.

A tendency to bleed after any invasive procedure.

Mucosal bleeding.
Blood-tinged sputum after coughing.
Discoloration of the skin.
An increased platelet count.

Correct Answer:
1. A tendency to bleed after any invasive procedure.
2. Mucosal bleeding.
3. Blood-tinged sputum after coughing.
4. Discoloration of the skin.
Rationale:
A tendency to bleed after any invasive procedure. Thrombocytopenia is defined as a decrease in
the number of circulating platelets caused by impaired or suppressed production of platelets or
accelerated destruction of platelets. This results in a clotting failure and the tendency to bleed.
Mucosal bleeding. Thrombocytopenia is defined as a decrease in the number of circulating
platelets caused by impaired or suppressed production of platelets or accelerated destruction of
platelets. This results in a clotting failure and the tendency to bleed when tissue is aggravated.
Blood-tinged sputum after coughing. Coughing causes stress on tissues that may stimulate
bleeding due to the decrease in circulating platelets.
Discoloration of the skin. Skin discoloration is caused by bleeding into the tissues, an effect of
bleeding and decreased platelets.
An increased platelet count. Thrombocytopenia results from a decrease in the number of
circulating platelets.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

6. Immune thrombocytopenia purpura (ITP) is an immune disease marked by a decrease in the

number of platelets due to:
1.
2.
3.
4.

Destruction by antibodies produced against a clients own platelets.

An overproduction of reticulocytes.
An overproduction of neutrophils.
A reaction to heparin therapy.

Correct Answer: Destruction by antibodies produced against an individuals own platelets.

Rationale: Immune thrombocytopenic purpura (ITP) is an autoimmune disease marked by a
decrease in the number of platelets due to destruction by antibodies produced against a clients
own platelets. It is categorized as secondary and primary. Secondary ITP refers to the appropriate
development of antibodies against invading pathogens or drugs, which then inappropriately crossreact against platelets, causing their destruction. In primary ITP, antibodies against platelets also
surface, but occur in the absence of viral, bacterial, or drug exposure. An overproduction of
immature red blood cells, reticulocytes. does not affect the number of platelets. An overproduction
of white blood cells, such as neutrophils, does not diminish the number of platelets. A reaction to
heparin therapy is referred to as heparin-induced thrombocytopenia and results from being treated
with unfractionated heparin and frequent exposure to diluted heparin flushes for IV therapy
management.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

7. In developing a teaching plan for a client who is at home and has thrombocytopenia, the nurse
should consider:
Select all that apply.
1.
2.
3.
4.

Developing a plan for physical exercise.

Discussing the home environment with patient and family to ensure safety.
Assisting the client/family to develop an awareness of bleeding precautions.
Collaborating with the pharmacist to identify drugs that might exacerbate the destruction of
platelets.
5. Discussing the need to reduce alcohol and increase thiazide medications.
Correct Answer:
1. Developing a plan for physical exercise.
2. Discussing the home environment with patient and family to ensure safety.
3. Assisting the client/family to develop an awareness of bleeding precautions.
4. Collaborating with the pharmacist to identify drugs that might exacerbate the destruction of
platelets.
Rationale:
Developing a plan for physical exercise. The client should engage in physical exercise that will
maintain cardio-muscular strength, but not expose the client to injury.
Discussing the home environment with patient and family to ensure safety. The home
environment should be free from safety hazards that may cause falls or other types of physical
injury.
Assisting the client/family to develop an awareness of bleeding precautions. The client should
be aware of bleeding precautions such as using a soft toothbrush or tooth sponges for mouth care,
avoiding rectal thermometers and enemas, and preventing constipation and straining with stools.
Collaborating with the pharmacist to identify drugs that might exacerbate the destruction of
platelets. Medications in the form of prescriptions and over-the-counter drugs may contribute to
bleeding problems.
Discussing the need to reduce alcohol and increase thiazide medications. Alcohol has a
marrow-depressing effect leading to transient thrombocytopenia; its use should be reduced.
Thiazide medications can produce mild thrombocytopenia; their use should be reduced.
Cognitive Level: Evaluation
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

8. A client diagnosed with hemolytic anemia typically presents with the following symptoms:
Select all that apply.
1.
2.
3.
4.
5.

Tachycardia.
Jaundice.
Hepatomegaly.
Decreased urine output.
Increased urine output.

Correct Answer:
1. Tachycardia.
2. Jaundice.
3. Hepatomegaly.
4. Decreased urine output.
Rationale:
Tachycardia. Tachycardia is a result of decreased oxygenation in anemia.
Jaundice. Jaundice results from an increase in indirect billirubin in hemolysis.
Hepatomegaly. Hepatomegaly, particularly in combination with poor liver function, is an indicator
of persistent hemolysis.
Decreased urine output. Decreased urine output is an indication of renal failure.
Increased urine output. Increased urine output would be atypical; decreased urine output is an
indication of renal failure.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

9. A positive response to iron therapy is evidenced by an increase in:

1.
2.
3.
4.

Reticulocytes.
Basophils.
Eosinophils.
Platelets.

Correct Answer: Reticulocytes.

Rationale: Reticulocytes are red blood cells that respond positively to iron therapy, resulting in
increased reticulocytes. Basophils and eosinophils are types of white blood cells whose growth is
not influenced by iron therapy. Platelets cells are necessary for clotting but are not responsive to
iron therapy.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

10. The laboratory test results for a client with hemophilia will include which of the following?
1.
2.
3.
4.

Prolonged partial thromboplastin time (PTT)

INR (international normalized ratio) in the normal range
Normal prothrombin time (PT)
Normal bleeding time

Correct Answer: Prolonged partial thromboplastin time (PTT)

Rationale: A PTT and INR are indicated for any patient suspected of having hemophilia. An
increased or prolonged PTT is indicative of clotting factor deficiency or hemophilia. The INR time
also would be increased beyond the normal range in accordance with the prolonged prothrombin
time results. A normal PT and bleeding time are not indicative of a clotting factor disorder.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

11. A client admitted with iron deficiency anemia has clinical symptoms related to which abnormal
laboratory value?
1.
2.
3.
4.

Low levels of iron-bound transferrin

High levels of iron-bound transferrin
High levels of ferritin
High hemoglobin level

Correct Answer: Low levels of iron-bound transferrin

Rationale: Iron is required for the heme portion of the hemoglobin protein; it is coupled with the
iron-transporting protein transferrin. Thus erythrocyte production is slowed when iron-dependent
hemoglobin supplies are depleted or insufficient in contrast to high levels of ferritin, which may
indicate other types of anemiashemolytic, pernicious, and folic acid deficiency, liver damage, or
thalassemia. Ferritin is an iron-storage protein that is produced in the liver, spleen, and bone
marrow. High ferritin levels are related to the amount of iron stored in the body tissues, and would
indicate disorders related to chronic diseases such as leukemia, lymphoma, iron overload, and
tissue damage. A high hemoglobin level indicates hemoconcentration resulting from dehydration,
which does not typically occur in iron deficiency anemia.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

12. Megaloblastic anemia results from impaired DNA synthesis of the erythrocyte RBC precursors,
resulting in:
1.
2.
3.
4.

Large immature red blood cells, called megaloblasts.

Small, pale red blood cells.
Juvenile red blood cells, called reticulocytes.
Elongated, hard, sticky, cells.

Correct Answer: Large immature red blood cells, termed megaloblasts.

Rationale: Impaired DNA synthesis of the erythrocyte RBC precursors produce cells called
megaloblasts. Due to their immaturity and large size, these cells are often sequestered in the bone
marrow rather than released into the periphery. If released into the peripheral bloodstream,
megaloblasts are subject to an increased rate of hemolysis due to structural defects in their
membranes. Bone marrow sequestration and increased hemolysis result in a decreased total RBC
count or anemia. Small, pale red blood cells are reflective of iron deficiency anemia. Reticulocytes
are juvenile erythrocytes present in peripheral blood. Reticulocytes increase in most types of
sustained anemia, as erythropoiesis accelerates as a compensatory mechanism. Their presence is
not indicative of megaloblastic anemia. Elongated, hard, sticky, cells are found in sickle cell
anemia.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

13. What is the goal of nursing management when caring for a hospitalized client with hemophilia?
Select all that apply.
1.
2.
3.
4.
5.

Disease management
Environmental control
Client/family education
Administration of replacement factors
Cure

Correct Answer:
1. Disease management
2. Environmental control
3. Client/family education
4. Administration of replacement factors
Rationale:
Disease management. Disease management focuses on reduction of environmental factors that
increase risk and on management of the administration of the replacement factors.
Environmental control. Disease management focuses on reduction of environmental factors that
increase risk and on management of the administration of the replacement factors.
Client/family education. Client/family education is critical to ensuring that they understand the
disease process and comply with the goals of the disease management plan.
Administration of replacement factors. Disease management focuses on reduction of
environmental factors that increase risk and on management of the administration of the
replacement factors.
Cure. Hemophilia is a chronic condition caused by the inheritance of mutated clotting genes
controlling Factor VIII or Factor IX, for which there is no cure. The goal of treatment revolves
around factor replacement therapy.
Cognitive Level: Analysis
Nursing Process: Implementation
Client Need: Safe, Effective Care Environment
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

14. A nurse is assigned to care for a female client diagnosed with aplastic anemia. What are the
expected outcomes of the nurses interventions?
Select all that apply.
1.
2.
3.
4.
5.

Free of injury from falls

Able to perform own ADLs
Alert and oriented
Hematocrit of 32
Dyspnea upon exertion

Correct Answer:
1. Free of injury from falls
2. Able to perform own ADLs
3. Alert and oriented
Rationale:
Free of injury from falls. The patient with aplastic anemia benefits from nursing interventions
designed for anemia, thrombocytopenia, and infection prevention. Free from falls indicates that the
client has enough muscle strength to ambulate safely, without falls.
Able to perform own ADLs. The patient with aplastic anemia benefits from nursing interventions
designed for anemia, thrombocytopenia, and infection prevention. This indicates that the patient
has enough energy based on oxygenation to perform her own ADLs.
Alert and oriented. Being alert and oriented indicates that the patient is getting enough oxygen to
the brain. In the cases of some anemia clients, this would not be satisfactory.
Hematocrit of 32. This is a low value for female hematocrit and is therefore incorrect.
Dyspnea upon exertion. The patient with aplastic anemia benefits form nursing interventions
designed for anemia, thrombocytopenia, and infection prevention. This indicates that the patient
becomes hypoxic with exertion, which is not a desired outcome.
Cognitive Level: Synthesis
Nursing Process: Evaluation
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

15. In preparing to care for a client with clotting disorders, the nurse reviews the types (categories)
of medications the client is likely to receive, including:
1.
2.
3.
4.

Immune-suppressive medications.
Erythropoietic agents.
Parenteral iron supplementation.
Vitamin supplementation.

Correct Answer: Immune-suppressive medications.

Rationale: Immune-suppressive medications, such as steroids and intravenous immunoglobulin,
are used to suppress the immune response, including the autoimmune response. Suppression of the
immune system results in platelet survival. Erythropoietic agents are used to treat anemias by
stimulating, differentiating, and proliferating the hematopoietic cascade. Parenteral iron
supplements and vitamin supplements also are used to treat anemias. Parenteral iron
supplementation stimulates the release of iron from plasma. Vitamin supplementation is used to
correct deficiencies in key elements, such as vitamin B12 and serum folate, required for hemoglobin
synthesis.
Cognitive Level: Analysis
Nursing Process: Planning
Client Need Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

16. The nurse is caring for a client who is on coumadin due to a history of deep vein thrombosis.
The teaching plan for the client must include instructions to avoid which of the following food
choices?
1.
2.
3.
4.

Dark-green leafy vegetables

Fish
Fruit
Red meat

Correct Answer: Dark-green leafy vegetables

Rationale: Dark-green leafy vegetables contain vitamin K, thus they would counteract the effects
of coumadin. Fish, fruit, and red meat do not contain vitamin K, and would be safe to include in
the diet.
Cognitive Level: Evaluation
Nursing Process: Implementation
Client Need: Health Promotion and Maintenance
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

17. The nurse is admitting a client to the emergency department who is bleeding from a gunshot
wound to the right thigh. The nurse is unable to stop the bleeding. What diagnostic tests must be
performed on this client?
Select all that apply.
1.
2.
3.
4.
5.

Platelet count
INR (international normalized ratio)
PTT (partial thromboplastin time)
WBC (white blood count)
BUN (blood urea nitrogen)

Correct Answer:
1. Platelet count
2. INR (international normalized ratio)
3. PTT (partial thromboplastin time)
Rationale:
Platelet count. The platelet count measures the circulating platelets in the blood; platelets
facilitate the clotting process. INR (international normalized ratio). The international
normalized ratio monitors anticoagulant therapy, and it is generally used to monitor coumadin
therapy. PTT (partial thromboplastin time). Partial thromboplastin time is a screening test used
to detect deficiencies in all clotting factors except VII and XIII and to detect platelet variations.
WBC (white blood count). The white blood count (WBC) is part of a complete blood count and is
used to determine the presence of an infection. BUN (blood urea nitrogen). The blood urea
nitrogen (BUN) measures the urea excreted by the kidneys and is used to detect a renal disorder or
dehydration associated with increased BUN levels.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.

18. The nurse is caring for a postoperative hip fracture client who is complaining of chest pain and
shortness of breath. What laboratory tests must be ordered for this client?
Select all that apply.
1.
2.
3.
4.
5.

Platelet count
PTT
INR
WBC
BUN

Correct Answer:
1. Platelet count
2. PTT
Rationale:
Platelet count. The client is at high risk for a clotting disorder to develop. The platelet count
measures the circulating platelets in the blood; platelets facilitate the clotting process. PTT. Partial
thromboplastin time is a screening test used to detect deficiencies in all clotting factors except VII
and XIII and to detect platelet variations, thus it would be appropriate to order. INR. The
international normalized ratio monitors anticoagulant therapy, and it is generally used to monitor
coumadin therapy. This client has not been diagnosed for the chest pain and has not been placed on
anticoagulant therapy. WBC. The white blood count (WBC) is part of a complete blood count and
is used to determine the presence of an infection, and would not be ordered. BUN. The blood urea
nitrogen (BUN) measures the urea excreted by the kidneys and is used to detect a renal disorder or
dehydration associated with increased BUN levels, and would be ordered to determine the cause of
chest pain and shortness of breath.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation

for Practice Copyright 2010 by Pearson Education, Inc.