CCRN - Review Hematology and Immunology Questions and Answers 1 — Questions and Answers
Question 1: A patient with severe sepsis begins bleeding from venipuncture sites and around their central line. Laboratory results show a platelet count of 45,000/mm³, prolonged PT and aPTT, a fibrinogen level of 80 mg/dL, and an elevated D-dimer. These findings are most indicative of which hematologic complication?
- Heparin-Induced Thrombocytopenia (HIT)
- Thrombotic Thrombocytopenic Purpura (TTP)
- Disseminated Intravascular Coagulation (DIC) (Correct answer)
- Vitamin K Deficiency
Correct answer: Disseminated Intravascular Coagulation (DIC)
Disseminated Intravascular Coagulation (DIC) is a complex syndrome characterized by widespread systemic activation of coagulation, leading to the formation of microthrombi and consumption of clotting factors and platelets. This consumptive coagulopathy results in the paradoxical combination of thrombosis and hemorrhage. The lab profile presented—thrombocytopenia, prolonged clotting times, low fibrinogen, and elevated D-dimer (a fibrin degradation product)—is the classic presentation of DIC, especially in the context of sepsis.
Question 2: A patient has been receiving a continuous heparin infusion for five days for a pulmonary embolism. The nurse notes that the patient's platelet count has dropped from 210,000/mm³ on admission to 90,000/mm³. The nurse suspects Heparin-Induced Thrombocytopenia (HIT). What is the priority nursing intervention?
- Administer a STAT dose of protamine sulfate.
- Request an order for a platelet transfusion.
- Continue the infusion and notify the provider on their next rounds.
- Immediately stop the heparin infusion and notify the healthcare provider. (Correct answer)
Correct answer: Immediately stop the heparin infusion and notify the healthcare provider.
The priority intervention for suspected HIT is to immediately discontinue all sources of heparin, including the infusion and any heparin-containing flushes. HIT is an immune-mediated reaction that causes a paradoxical prothrombotic state despite the drop in platelets. Continuing heparin would worsen the condition. Notifying the provider is critical, but the nurse's first independent action is to stop the offending agent. Platelet transfusion is generally contraindicated as it can 'add fuel to the fire' and increase the risk of thrombosis.
Question 3: A critical care nurse is caring for a patient with acute lymphoblastic leukemia who recently started an aggressive chemotherapy regimen. Which set of laboratory findings would be most characteristic of Tumor Lysis Syndrome (TLS)?
- Hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia (Correct answer)
- Hypokalemia, hypophosphatemia, hypouricemia, hypercalcemia
- Hyperkalemia, hypophosphatemia, hypouricemia, hypercalcemia
- Hypokalemia, hyperphosphatemia, hyperuricemia, hypocalcemia
Correct answer: Hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia
Tumor Lysis Syndrome (TLS) is a metabolic emergency caused by the massive and rapid death of cancer cells, releasing their intracellular contents into the bloodstream. This leads to hyperkalemia (from potassium release), hyperphosphatemia (from nucleic acid breakdown), and hyperuricemia (from nucleic acid breakdown). The high levels of phosphate bind with calcium, leading to secondary hypocalcemia.
Question 4: A patient in the ICU is receiving their first dose of a new intravenous antibiotic. Within minutes, the patient develops stridor, severe dyspnea, and a blood pressure of 70/40 mmHg. Which medication should the nurse prepare for immediate administration?
- Diphenhydramine 50 mg IV
- Epinephrine 0.3-0.5 mg IM (Correct answer)
- Methylprednisolone 125 mg IV
- Albuterol nebulizer treatment
Correct answer: Epinephrine 0.3-0.5 mg IM
The patient is exhibiting signs of anaphylactic shock, a life-threatening allergic reaction. The first-line and most critical treatment is intramuscular epinephrine. Epinephrine acts rapidly to cause vasoconstriction (increasing blood pressure), reduce mucosal edema (relieving stridor and airway obstruction), and induce bronchodilation. While antihistamines (diphenhydramine), corticosteroids (methylprednisolone), and bronchodilators (albuterol) are also used in managing anaphylaxis, they are considered adjunctive therapies and do not replace the immediate, life-saving effects of epinephrine.
Question 5: Fifteen minutes after the initiation of a packed red blood cell (PRBC) transfusion, the patient develops a fever, chills, severe flank pain, and hypotension. The nurse suspects an acute hemolytic transfusion reaction. What is the nurse's FIRST action?
- Administer acetaminophen for the fever.
- Notify the blood bank of the reaction.
- Stop the transfusion immediately. (Correct answer)
- Increase the rate of the primary normal saline infusion.
Correct answer: Stop the transfusion immediately.
The absolute priority and first action for any suspected transfusion reaction is to immediately stop the transfusion. This prevents the patient from receiving any more of the incompatible blood, which is causing the hemolytic reaction. After stopping the blood, the nurse should disconnect the blood tubing (while maintaining IV access with a new normal saline line), notify the provider and blood bank, monitor vital signs, and prepare to send the blood bag and tubing back for analysis.
Question 6: A patient who underwent a bone marrow transplant has an absolute neutrophil count (ANC) of 350/mm³. The patient's temperature is now 38.6° C (101.5° F). Which of the following physician orders should the nurse implement first?
- Administer acetaminophen 650 mg PO.
- Place the patient in protective isolation.
- Obtain blood cultures from two different sites.
- Administer a prescribed broad-spectrum antibiotic. (Correct answer)
Correct answer: Administer a prescribed broad-spectrum antibiotic.
Neutropenic fever is a medical emergency. An ANC less than 500/mm³ indicates severe neutropenia, and these patients cannot mount an effective immune response, making them highly susceptible to overwhelming infection. The standard of care is to administer broad-spectrum antibiotics as quickly as possible (ideally within one hour of fever presentation) to prevent sepsis and death. While obtaining blood cultures is crucial, it should not delay the administration of antibiotics. Antipyretics and isolation are important but are not the immediate life-saving priority.
CCRN - Review Hematology and Immunology Questions and Answers 1
A patient with severe sepsis begins bleeding from venipuncture sites and around their central line.
Laboratory results show a platelet count of 45,000/mm³, prolonged PT and aPTT, a fibrinogen level of 80 mg/dL, and an elevated D-dimer.
These findings are most indicative of which hematologic complication?