Week 2.

Anemia, Hemophilia, Polycythemia, Bone Marrow Failure

Name: _______________________ Section: ___________ Date: ___________

Multiple Choice.

1. The mother asks the nurse if her child's iron deficiency anemia is related to
the child's frequent infections. The nurse responds based on the
understanding of which of the following?
A. Little is known about iron-deficiency anemia and its relationship to
infection in children.
B. Children with iron deficiency anemia are more susceptible to infection
than are other children.
C. Children with iron-deficiency anemia are less susceptible to infection than
are other children.
D. Children with iron-deficient anemia are equally as susceptible to infection
as are other children.

RATIONALE: D. Children with iron-deficiency anemia are more susceptible

to infection because of marked decreases in bone marrow functioning with
microcytosis.

2. You are preparing the client for a bone marrow aspiration and biopsy. Which
of the following statements, if made by the patient, indicates the need for
further teaching?
A. After the procedure I should avoid ambulating for 24-48 hours
B. Pain and discomfort is expected after the surgery. I can take some
Tylenol for the discomfort.
C. I should not take a bath for about 24 hours
D. The surgeon will collect the samples from my hip bone

Rationale: A. There is no need to avoid ambulation after the biopsy.

Some discomfort at the site can occur for about a day or two. Tylenol
can be given in this case but aspirin based medications should be
avoid d/t risk for bleeding. The patient should be advised to avoid
taking a bath or submerging the site in any other way with water. The
specimen is typically taken from the iliac crest, part of the hip bone.

3. The clinic nurse instructs the mother of a child with sickle cell disease about
the precipitating factors related to pain crisis. Which of the following, if
identified by the mother as a precipitating factor, indicates the need for
further instructions?
A. Infection
B. Trauma
C. Fluid overload
D. Stress
RATIONALE: C. Pain crisis may be precipitated by infection, dehydration,
hypoxia, trauma, or physical or emotional stress. The mother of a child
with sickle cell disease should encourage fluid intake of 1 1/2 to 2 times
the daily requirement to prevent dehydration.

4. The patient who underwent a bone biopsy yesterday calls the office thinking
something is wrong. Which of the following would be cause for concern by
the nurse? SATA:
A. Swelling and redness at the site
B. Red streaks spreading away from the area
C. T of 99.5
D. Pain in the area

Rationale: A and B. These are signs of possible bleeding or infection at

the site. A temperature of 99.5 is still considered WNL. Pain in the area
would be expected (unusual or increased pain should be reported). A
small amount of blood on dressing would be expected. Any pus found
in the drainage should be reported.

5. 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

RATIONALE: A. Aplastic anemia decreases the bone marrow production of

RBCs, WBCs, and Platelets. The client is at risk for bruising and bleeding
tendencies.

6. Which of the following blood levels is usually abnormally high in a person

with polycythemia vera?
A. Hemoglobin
B. Erythropoietin
C. Sodium
D. Potassium

Rationale: a. The level of the protein that carries oxygen in blood cells
(hemoglobin) and the percentage of red blood cells in the total blood
volume (the hematocrit) are normally high. B. Levels of erythropoietin
(a hormone that stimulated bone marrow to produce red blood cells)
are extremely low in polycythemia vera.
7. 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 client's activity intolerance?
A. "What activities were you able to do 6 months ago compared with
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?"

RATIONALE: 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.

8. A child suspected of having sickle cell disease is seen in a clinic, and

laboratory studies are performed. A nurse checks the lab results, knowing
that which of the following would be increased in this disease?
A. Platelet count
B. Hematocrit level
C. Reticulocyte count
D. Hemoglobin level

RATIONALE: C. A diagnosis is established based on a complete blood

count, examination for sickled RBCs in the peripheral smear, and
hemoglobin electrophoresis. Lab studies will show decreased HGB and
HCT levels and a decreased platelet count, and increased reticulocyte
count, and the presence of nucleated RBCS. Increased reticulocyte counts
occur in children with sickle cell disease because the life span of their
sickled RBCS is shortened.

9. Which of the following is a common treatment for polycythemia vera?

a. Bisphosphonates
b. A high-protein diet
c. Vitamin C supplements
d. Phlebotomy

Rationale: d. The aim of treatment is to decrease the number of red blood

cells. Usually, blood is removed from the body in a procedure called
phlebotomy, similar to the way blood is removed when donating blood.

10.The patient diagnosed with iron deficiency anemia tells you that she
constantly feels tired and exhausted. She tells you that she is concerned
about this problem. What is the nurse's best initial response?
A. Keep taking your supplements and report back to me in a couple to days
B. How has this affected your life?
C. You are going to need to take a break from those things for a period of
time to rest
D. Try to help get rid of the stress in your life. This will help with the tired
feeling

Rationale: B. Asking this client explain how the fatigue is affecting her life
will help open up the conversation and build rapport. Fatigue is a real
life-changing issue for patients with anemia and should not be dismissed.
Telling her that she must take a break from "things" is not an
understanding response and may not solve the underlying problem.
Clients should not be instructed to get rid of all the stress in life.

11.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

RATIONALE: A. Eggs are high in Iron. Other foods high in iron are organ
meats, muscle meats; shellfish, shrimp, and tuna; enriched, whole-grain,
and fortified cereals and breads; legumes, nuts, dried fruits, and beans;
oatmeal; and sweet potatoes.

12.Which medication might the nurse question if administered to the client with
anemia?
A. Cipro
B. Lisinopril
C. Acetaminophen
D. Ferrous sulfate

Rationale: B. An antihypertensive medication such as an ACE inhibitor

could decrease the preload even further which could be detrimental for a
patient with anemia. An antibiotic or Tylenol should not affect the anemia
problem directly. Ferrous sulfate is often prescribed to patients with
anemia to help bring up RBC.

13.Polycythemia vera is a disorder of the blood-producing cells of the bone

marrow. This disorder results in which of the following?
A. Underproduction of white blood cells
B. Underproduction of platelets
C. Overproduction of red blood cells
D. Overproduction of bone cells

Rationale: c. Overproduction of red blood cells. Choices A, B, and D result

from other disorders.

14.In which of the following diseases would bone marrow transplantation not be
indicated in a newly diagnosed client?
A. Severe aplastic anemia
B. Severe combined immunodeficiency
C. Acute lymphocytic leukemia
D. Chronic myeloid leukemia

Rationale: C. For the first episode of acute lymphocytic leukemia,

conventional therapy is superior to bone marrow transplantation.
Treatment is usually long-term chemotherapy and is composed of 3
phases (induction, consolidation, and maintenance).

15.A client has a bone marrow biopsy done. Which nursing intervention is the
priority post-procedure?
A. Applying pressure to the biopsy site
B. Inspecting the site for ecchymoses
C. Sending the biopsy specimens to the laboratory
D. Teaching the client about avoiding vigorous activity

Rationale: A, The initial action should be to stop bleeding by applying

pressure to the site. Inspecting for ecchymoses, sending specimens to
the laboratory, and teaching the client about activity levels will be done
after hemostasis has been achieved.

16.When excessive bleeding occurs, which of the following causes blood

pressure to fall?
A. The amount of fluid left in the blood vessels is insufficient.
B. The body's oxygen supply is increased.
C. The iron in the blood is decreased.
D. Production of red blood cells increases.

Rationale: A. The amount of fluid left in the blood vessels is

insufficient. B: Losing a large amount of blood suddenly can cause the
body’s oxygen supply to be decreased. C: Over time, bleeding reduces
the amount of iron in the body. D: Anemia due to excessive bleeding
results when loss of red blood cells exceeds production of new red
blood cells.
17.Which of the following is not typically a symptom of autoimmune hemolytic
anemia?
A. Easy bruising
B. Fatigue
C. Mild jaundice
D. Spleen enlargement

Rationale: A. Easy bruising. Choice B: Fatigue, along with weakness

and paleness, is typical and is similar to symptoms of other forms of
anemia. These symptoms tend to occur particularly when destruction
of red blood cells is more severe or rapid. Choice C: Mild jaundice may
also develop when destruction of red blood cells is more severe or
rapid. Choice D: Spleen enlargement may occur when destruction
occurs over a period of months. It may result in the sensation of
abdominal fullness or, occasionally, discomfort.

18.A mother asks the nurse if her child's iron deficiency anemia is related to the
child's frequent infections. The nurse responds based on the understanding of
which of the following?
A. Little is known about iron-deficiency anemia and its relationship to
infection in children.
B. Children with iron deficiency anemia are more susceptible to infection
than are other children.
C. Children with iron-deficiency anemia are less susceptible to infection
than are other children.
D. Children with iron-deficient anemia are equally as susceptible to
infection as are other children.

Rationale: b. If iron deficiency anaemia is left untreated, it can make

you more susceptible to illness and infection, as a lack of iron affects
the body's natural defence system (the immune system).

19.Which of the following disorders results from a deficiency of factor VIII?

A. Sickle cell disease
B. Christmas disease
C. Hemophilia A
D. Hemophilia B

RATIONALE: C. Hemophilia A results from a deficiency of factor 8. Sickle

cell disease is caused by a defective hemoglobin molecule. Christmas
disease, AKA Hemophilia B, results in a factor 9 deficiency.

20.Which blood test result for a client being assessed for a hematologic problem
indicates to the nurse that chronic anemia is likely?
A. International normalized ratio (INR) is 0.9
B. Platelet count of 180,000/mm3
C. Reticulocyte value of 14%
D. Hematocrit of 27%

RATIONALE: c. The normal reticulocyte value is 2% or less of the total

red blood cell (RBC) count. A reticulocyte is an immature RBC that still
has its nucleus. An elevated reticulocyte count indicates that RBCs are
being produced and released by the bone marrow before they mature.
This often happens when a person has a condition that causes
continual but very slow bleeding and anemia. This client has a low
hematocrit and is anemic. The INR and platelet values are normal

21.Which of the following is usually the first treatment given to patients with
autoimmune hemolytic anemia?
A. Corticosteroid
B. Blood transfusions
C. Immunosuppressant drugs
D. Removal of the spleen

Rationale: A. A corticosteroid, such as prednisone, is usually the first

treatment, although if symptoms are very mild, no treatment may be
needed. Choice B: When red blood cell destruction is severe, blood
transfusions are sometimes needed. Choice C: When destruction of red
blood cells persists after removal of the spleen, or the spleen cannot
be removed, immune suppressants, such as cyclosporine, may be
used. Choice D: If a patient does not respond to corticosteroids, or has
intolerable side effects, the next step may be surgical removal of the
spleen (splenectomy).

22.A client receiving high-dose chemotherapy who has bone marrow

suppression has been receiving daily injections of epoetin alfa (Procrit).
Which assessment finding indicates to the nurse that today's dose should be
held and the health care provider notified?
A. Hematocrit of 28%
B. Total white blood cell count of 6200 cells/mm3
C. Blood pressure change from 130/90 mm Hg to 148/98 mm Hg
D. Temperature change from 99° F (37.2 C) to 100 F (37.8 C)

Rationale: C. Epoetin alfa and other erythropoiesis-stimulating agents

(ESAs) such as darbepoetin alfa (Aranesp) and epoetin alfa (Epogen,
Procrit) increase the production of many blood cell types, not just
erythrocytes, which increases the client's risk for hypertension, blood
clots, strokes, and heart attacks, especially among older adults. Dosing is
based on individual client hemoglobin and hematocrit levels to ensure that
just enough red blood cells are produced to avoid the need for transfusion
but not to bring hemoglobin or hematocrit levels up to normal. The
increased blood pressure is an indication to stop this therapy immediately.

23.The nurse understands that the client with pernicious anemia will have which
distinguishing laboratory findings?
A. Schilling's test, elevated
B. Intrinsic factor, absent
C. Sedimentation rate, 16 mm/hour
D. RBCs 5.0 million

RATIONALE: 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.

24.Imagine this. You enter the unit as an RN on your first day on the job. You
breathe in the smell of awesomeness and drink your Starbucks coffee. You
see that you are taking care of a Mr. Smith who has been diagnosed
Polycythemia Vera. Because you are so freakin' awesome, you know that Mr.
Smith is at risk for which of the following complications?
A. Excessive Bleeding
B. Pruritus
C. Hepatomegaly
D. Pancreatitis

Rationale: A. Mr. Smith is at risk for bleeding because of overgrown,

dysfunctional platelets r/t his disease process. He is also at risk for clot
formation and therefore at risk for a CVA or MI. Pruritis would be an expected
symptom of his disease, not a complication. Splenomegaly, not
hepatomegaly, is associated with this disorder. Pancreatitis was a red herring,
sorry.
25.Autoimmune hemolytic anemia is a group of disorders characterized by a
malfunction of the immune system. Patients with this disorder produce
autoantibodies that attack red blood cells as if they were substances foreign
to the body. Which of the following causes about half of all cases of
autoimmune hemolytic anemia?
A. Genetic anomaly
B. Another coexisting autoimmune disorder, such as systemic lupus
erythematosus (lupus)
C. Use of certain drugs, such as penicillin
D. An undetermined cause

Rationale: d. About half the time, the cause of autoimmune hemolytic

anemia cannot be determined; this is called idiopathic autoimmune
hemolytic anemia. Choice A is incorrect. Choices B and C are other,
less common causes of autoimmune hemolytic anemia.

26. A patient is about to undergo bone marrow aspiration and biopsy and
expresses fear and anxiety about the procedure. Which of the following is the
most effective nursing response?
A. Warn the patient to stay very still because the smallest movement will
increase her pain.
B. Encourage the family to stay in the room for the procedure.
C. Stay with the patient and focus on slow deep breathing for relaxation.
D. Delay the procedure to allow the patient to deal with her feelings.

Rationale: c. Slow deep breathing is the most effective method of

reducing anxiety and stress. It reduces the level of carbon dioxide in
the brain to increase calm and relaxation. Warning the patient to
remain still will likely increase the anxiety. Encouraging family
members to stay with the patient may make her worry about their
anxiety as well as her own. Delaying the procedure is unlikely to allay
her fears.

27.Which of the following is both the standard treatment and also a potential
cure for aplastic anemia?
A. Antithymocyte globulin
B. Cyclosporine
C. Stem cell transplantation
D. Transfusions

Rationale: c. Stem cell transplantation is the standard treatment for

aplastic anemia. It is potentially curative, especially in younger people
with a matched stem cell donor. Choices A and B: If stem cell
transplantation is not possible, people are given antithymocyte globulin
and cyclosporine to suppress the immune system and allow the bone
marrow stem cells to regenerate. Choice D: Transfusions of red blood
cells, platelets, and substances called “growth factors” may
temporarily increase the number of red blood cells, white blood cells,
and platelets. However, as transfusions may prevent subsequent stem
cell transplantation, it is done only when essential.

28.The usual treatment for iron-deficiency anemia includes:

A. Vitamin B12 injection
B. Non-enteric-coated ferrous sulfate
C. Enteric-coated or sustained-release ferrous sulfate
D. Whole blood transfusion

Rationale: b. The usual tx is 325 mg p.o. daily. enteric-coated and

sustained rls formulas should be avoided, as they are poorly absorbed

29.A newly admitted client has an elevated reticulocyte count. Which disorder
does the nurse suspect in this client?
A. Aplastic anemia
B. Hemolytic anemia
C. Infectious process
D. Leukemia

Rationale: B. An elevated reticulocyte count in the anemic client

indicates that the bone marrow is responding appropriately to a
decrease in the total red blood cell (RBC) mass and is prematurely
destroying red blood cells. Therefore more immature RBCs are in
circulation. Aplastic anemia is associated with a low reticulocyte count.
A high white blood cell count is expected in clients with infection, while
a low WBC is expected in clients with leukemia

30.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

RATIONALE: 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.

31.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 client's activity intolerance?
A. "What activities were you able to do 6 months ago compared with
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?"

Rationale: 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

32.A client is scheduled for a bone marrow aspiration. What does the client's
nurse do before taking the client to the treatment room for the biopsy?
A. Cleans the biopsy site with an antiseptic or povidone-iodine (Betadine)
B. Holds the client's hand and asks about concerns
C. Reviews the client's platelet (thrombocyte) count
D. Verifies that the client has given informed consent

Rationale: d. Verifying informed consent must be done before the

procedure can be performed. A signed permit must be on the client's
chart. Cleaning the biopsy site is done before the procedure but is not
the first thing that should be done. It is not done until consent is
verified. It will be done just before the procedure is performed.

33.Which of the following is the most common way a diagnosis of anemia is

confirmed?
A. Measuring hemoglobin or hematocrit (percentage of red blood cells in
total blood volume) levels in a blood sample
B. Measuring performance on a cardiac stress test
C. Measuring the number of red blood cells in a bone marrow sample
D. Visually examining the color of a blood sample
Rationale: A. Measuring hemoglobin or hematocrit levels in a blood
sample. Low levels typically confirm a diagnosis of anemia. Choices B
and D are incorrect. C: Bone marrow examination may provide
information about the cause of a person’s anemia, but it does not
confirm the diagnosis.

34. A vegetarian client was referred to a dietitian 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

RATIONALE: C. Coffee and tea increase gastrointestinal motility 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.

35.The term “leukopenia” is the medical term for which of the following?
A. Easy bleeding and bruising
B. Too few platelets
C. Too few red blood cells
D. Too few white blood cells

Rationale: D. The term “leukopenia” is the medical term for too few
white blood cells. Choice A is incorrect. Choice B: Easy bleeding and
bruising are caused by “thrombocytopenia,” the medical term for too
few platelets. Choice C: The medical term for too few red blood cells is
“anemia.”

36.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 client's 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?"
RATIONALE: 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 client's 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 client's 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.

37.Anemia is a condition in which the number of red blood cells or the amount of
hemoglobin (the protein that carries oxygen in red blood cells) is low. Which
of the following is NOT one of the mechanisms that can lead to anemia?
A. Blood loss (excessive bleeding)
B. Excessive destruction of red blood cells
C. Inadequate production of red blood cells
D. Inadequate production of white blood cells

Rationale: D. Inadequate production of white blood cells. It is the

number and quality of the red blood cells, not white, that are involved
in the development of anemia. Choices A, B, and C are all mechanisms
that can lead to anemia.

38.A nurse is reviewing complete blood count (CBC) data for a 76-year-old
client. Which decreased value causes concern because it is not age related?
A. Hemoglobin (Hgb) level
B. Platelet (thrombocyte) count
C. Red blood cell (RBC) count
D. White blood cell (WBC) response

Rationale: b. Platelet counts do not generally change with age.

Hemoglobin levels in men and women fall after middle age.
Iron-deficient diets may play a role in this reduction. Total red blood
cell (RBC) and white blood cell (WBC) counts (especially lymphocyte
counts) are lower in older adults. The WBC count does not rise as high
in response to infection in older adults as it does in younger people.
39.Most but not all symptoms of anemia are similar in older and younger people.
Which of the following symptoms is more likely to occur in older people with
anemia than in younger people with anemia?
A. Confusion and agitation
B. Increased thirst
C. Shortness of breath
D. Weak and rapid pulse

Rationale: A. Even when anemia is mild, older people are more likely
than younger people to develop confusion, agitation, depression,
and/or listlessness. B, C, and D: These symptoms occur with similar
frequency in younger and older people with anemia.

40.Which of the following causes of long-term blood loss may NOT cause
noticeable symptoms?
A. Bleeding from the kidneys.
B. Heavy menstrual bleeding.
C. Intestinal polyps.
D. Ruptured blood vessel.

Rationale: c. Intestinal polyps. A: Bleeding from a kidney may cause

dark red or brown urine. B: Heavy menstrual bleeding is usually
obvious. D: A ruptured blood vessel is usually an acute condition that
causes obvious symptoms.

41.Bone marrow samples are usually taken from which part of the body?
A. Arm bone
B. Breastbone
C. Hipbone
D. Leg bone
Rationale: c. Bone marrow samples are usually taken from the hipbone
(iliac crest), although aspirates are rarely taken from the breastbone
(sternum—choice B). D: In very young children, bone marrow samples
are occasionally taken from one of the bones in the lower leg (tibia).

42.A nurse is teaching a client about what to expect during a bone marrow
biopsy. Which statement by the nurse accurately describes the procedure?
A. "The doctor will place a small needle in your back and will withdraw
some fluid."
B. "You may experience a crunching sound or a scraping sensation as the
needle punctures your bone."
C. "You will be alone because the procedure is a sterile one; we cannot
allow additional people to contaminate the area."
D. "You will be sedated, so you will not be aware of anything."
Rationale: B. This description is accurate. Proper expectations
minimize the client's fear during the procedure. A very large-bore
needle is used for a bone marrow biopsy, not a small needle. The
puncture is made in the hip or in the sternum, not the back. The
nurse, or sometimes a family member, is available to the client for
support during a bone marrow biopsy. The procedure is sterile at the
site of the biopsy, but others can be present without contamination at
the site. A local anesthetic agent is injected into the skin around the
site. The client may also receive a mild tranquilizer or a rapid-acting
sedative (such as lorazepam [Ativan]) but will not be completely
sedated. Clients are aware of what is happening during the procedure.

43.Aplastic anemia is a disorder in which the bone marrow cells that develop
into mature blood cells become damaged. The damaged bone marrow cells
can lead to low numbers of red blood cells, white blood cells, and/or
platelets. When the cause of aplastic anemia cannot be diagnosed, the cause
is likely which of the following?
A. An autoimmune disorder
B. Chemotherapy drugs
C. Radiation exposure
D. Toxins

Rationale: A. An autoimmune disorder. When the cause of aplastic

anemia cannot be diagnosed (“idiopathic aplastic anemia”), the cause
is likely an autoimmune disorder in which the immune system
suppresses bone marrow stem cells. Stem cells are undifferentiated
cells that can develop into any body cells. Choices B, C, and D are
other causes of aplastic anemia.

44.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

Rationale: a. Aplastic anemia decreases the bone marrow production

of RBCs, WBCs, and Platelets (aka pancytopenia, the decrease in
overall CBC's). The client is at risk for bruising and bleeding
tendencies. The patient is also at risk for infections

45.The primary purpose of the Schilling test is to measure the client's ability to:
A. Store vitamin B12
B. Digest vitamin B12
C. Absorb vitamin B12
D. Produce vitamin B12

RATIONALE: Pernicious anemia is caused by the body's inability to absorb

vitamin B12. This results in a lack of intrinsic factor in the gastric juices.
Schilling's test helps diagnose pernicious anemia by determining the
client's ability to absorb vitamin B12.

46.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

RATIONALE: 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 non-radioactive 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.

47.A client with anemia asks, "Why am I feeling tired all the time?" How does
the nurse respond?
A. "How many hours are you sleeping at night?"
B. "You are not getting enough iron."
C. "You need to rest more when you are sick."
D. "Your cells are delivering less oxygen than you need."

Rationale: D. The single most common symptom of anemia is fatigue.

This problem occurs because oxygen delivery to cells is less than is
required to meet normal oxygen needs.

48.A client has a bone marrow biopsy done. Which nursing intervention is the
priority post procedure?
A. Applying pressure to the biopsy site
B. Inspecting the site for ecchymoses
C. Sending the biopsy specimens to the laboratory
D. Teaching the client about avoiding vigorous activity

RATIONALE: A. The initial action should be to stop bleeding by applying

pressure to the site. Inspecting for ecchymoses, sending specimens to the
laboratory, and teaching the client about activity levels will be done after
hemostasis has been achieved.

49.Bleeding episodes in a person with hemophilia can be treated with:

A. Aspirin
B. Blood clotting drugs
C. Gene therapy
D. Blood clotting factor transfusions

Rationale: d. Transfusions of clotting factor extracted from plasma of

normal donated blood is used to control bleeding episodes. Choice A,
Aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs) such
as Aleve and others should be avoided by people with hemophilia.
These drugs interfere with the clotting action of blood platelets. B,
Clotting drugs are not available, but transfusions of clotting factor from
normal blood can be used. C. Gene therapy is experimental now, and
is not yet widely available.

50.A client with anemia asks the nurse, "Do most people have the same number
of red blood cells?" How does the nurse respond?
A. "No, they don't."
B. "The number varies with gender, age, and general health."
C. "Yes, they do."
D. "You have fewer red blood cells because you have anemia."'

Rationale: B. This is the most educational and reasonable response to

the client's question. The first option is true, but not informative.

Prepared by: Dr. Jhonnifer A. Abarao,

DHCM, MAN, USRN, RN, LPT, CHA,

“Not all angels have wings … some have scrubs.” —Unknown