Question set B: heme and oncology, next-generation formats

The three falling platelet counts

Consumptive coagulopathy consumes platelets and fibrinogen while raising D-dimer, and the patient clots and bleeds at the same time. Heparin-induced thrombocytopenia drops the count sharply several days after heparin exposure and causes clotting rather than bleeding, and every heparin source including line flushes is stopped. Immune thrombocytopenia lowers platelets alone, with petechiae, normal coagulation studies, and no consumption pattern.

11. Matrix. Assign each finding to the reaction it best indicates: acute hemolytic, febrile nonhemolytic, transfusion-related acute lung injury, or transfusion-associated circulatory overload. a. Flank pain with dark red urine ten minutes into the unit b. Temperature rise with chills, blood pressure unchanged c. Abrupt hypoxemia with bilateral infiltrates, no jugular distension, no response to a diuretic d. Dyspnea with hypertension, jugular distension, and crackles that improve with sitting upright and diuresis

Answers: a — acute hemolytic. b — febrile nonhemolytic. c — transfusion-related acute lung injury. d — transfusion-associated circulatory overload. Why a is hemolytic: ABO incompatibility destroys cells within minutes and free hemoglobin colors the urine. Why b is febrile nonhemolytic: fever without hypotension is the defining pattern, and it still requires stopping the unit. Why c is lung injury: the diuretic non-response and absent volume overload separate it from circulatory overload. Why d is circulatory overload: hypertension and jugular distension mean too much volume, not an immune event. The rule: blood pressure sorts these four faster than any other single finding. Procedure verified against AABB standards; restart decisions are policy-dependent.

12. Bowtie. A patient with sepsis is oozing from two intravenous sites and a gum line. Platelets have fallen, fibrinogen is low, D-dimer is high. Select two actions, one condition, and two parameters to monitor. Actions: 1. Administer the prescribed broad-spectrum antibiotic for the underlying sepsis · 2. Minimize invasive procedures and apply prolonged pressure to puncture sites · 3. Ambulate the patient every two hours · 4. Massage the oozing sites Condition: 5. Disseminated intravascular coagulation · 6. Immune thrombocytopenia · 7. Hemophilia Parameters: 8. Platelet count · 9. Fibrinogen level · 10. Serum sodium · 11. Urine specific gravity

Answers: Actions 1 and 2. Condition 5. Parameters 8 and 9. Why 1 is right: treating the trigger is the only definitive therapy for consumptive coagulopathy. Why 2 is right: every puncture becomes a bleeding site when factors are consumed. Why 3 is wrong: ambulation does not address coagulopathy and adds fall-related bleeding risk. Why 4 is wrong: massage disrupts fragile clot. Why 6 is wrong: immune thrombocytopenia does not consume fibrinogen. Why 7 is wrong: hemophilia is inherited and does not follow sepsis. Why 10 and 11 are wrong: neither tracks consumption. The rule: bleeding and clotting at once, in a septic patient, is consumption.

13. Trend. Platelets: day 1, 210,000/mm³ · day 3, 180,000/mm³ · day 5, 74,000/mm³ · day 6, 51,000/mm³. Heparin started day 1. Fibrinogen normal, D-dimer normal, no bleeding, new swelling and pain in the right calf. Which condition does this trend indicate?

1. Disseminated intravascular coagulation 2. Heparin-induced thrombocytopenia 3. Immune thrombocytopenia 4. Splenic sequestration

Answer: 2. Why 2 is right: a sharp fall several days after heparin exposure, with thrombosis rather than bleeding, is the signature. Why 1 is wrong: fibrinogen and D-dimer would move in consumption. Why 3 is wrong: immune thrombocytopenia causes petechiae and bleeding, not calf thrombosis. Why 4 is wrong: sequestration follows splenomegaly, not heparin timing. The rule: low platelets plus a new clot means stop all heparin, including flushes. Anticoagulant class logic → BOOK 05 · P9.

14. Drop-down. Thirty-six hours after induction for a bulky lymphoma, the nurse expects potassium to be [__], phosphate to be [__], calcium to be [__], and uric acid to be [__]. Options for each blank: elevated · decreased · unchanged

Answers: elevated, elevated, decreased, elevated. Why: lysed cells release potassium, phosphate, and nucleic acids that become uric acid; released phosphate binds calcium and drives it down. Why "unchanged" is wrong for every blank: tumor lysis is defined by movement, and a flat panel excludes it. The rule: three up, one down, and the potassium is what kills.

15. Select all that apply. Which actions belong in the protective care of a patient with an absolute neutrophil count of 140/mm³?

1. Remove fresh flowers and standing water from the room
2. Take temperatures by the oral or axillary route, not rectally
3. Perform oral care with a soft brush after meals and at bedtime
4. Administer the scheduled live attenuated vaccine
5. Assess for fever every shift and report a single temperature promptly
6. Administer an as-needed antipyretic at the first temperature elevation

Answers: 1, 2, 3, 5. Why 1 is right: both harbor organisms this patient cannot fight. Why 2 is right: rectal trauma seeds bacteremia. Why 3 is right: mucositis is a portal of entry. Why 5 is right: one fever is the whole cue. Why 4 is wrong: live vaccines are contraindicated during profound neutropenia. Why 6 is wrong: an antipyretic first masks the only sign of infection. The rule: in neutropenia you protect barriers and you never blunt the fever. Precaution mechanics → BOOK 04 · P7.

16. A patient with metastatic breast cancer reports mid-back pain for three days that is worse when lying flat and now describes her legs as "heavy on the stairs." Which action is the priority?

1. Apply a heating pad and reassess in one hour
2. Notify the provider for urgent imaging and anticipate a corticosteroid order
3. Encourage bed rest in the flat position
4. Schedule physical therapy for gait training

Answer: 2. Why 2 is right: back pain worsened by lying flat plus new weakness in a cancer patient is cord compression, and deficits become permanent quickly. Why 1 is wrong: heat treats a muscle diagnosis nobody has established. Why 3 is wrong: flat positioning worsens the pain and delays imaging. Why 4 is wrong: therapy for weakness of unknown cause postpones the emergency. The rule: new back pain in cancer is imaged, not massaged.

17. Ordered response. During a vesicant infusion the patient reports burning at the site and the nurse cannot obtain a blood return. Place the actions in order.

1. Apply the temperature and antidote the specific agent requires
2. Stop the infusion
3. Aspirate residual drug through the catheter, leaving it in place
4. Photograph the site and document
5. Notify the provider

Answer: 2, 3, 5, 1, 4. Why that order: stopping halts further delivery; aspiration removes drug while access still exists; notification obtains the agent-specific order; treatment follows the order; documentation closes the event. Why removing the catheter first is wrong: it destroys the route for aspiration and antidote. Why treating before notification is wrong: the temperature and antidote differ by agent, and guessing causes injury. Why photographing first is wrong: it delays every action that limits tissue damage. The rule: stop, aspirate, notify, treat, document.

18. A 22-year-old in vaso-occlusive crisis has a pain score of 9. Which intervention is appropriate?

1. Apply cold packs to the painful joints
2. Restrict fluids to prevent volume overload
3. Provide the scheduled opioid on time with warmth to the affected areas and hourly incentive spirometry
4. Withhold analgesia until the pain score is verified on reassessment

Answer: 3. Why 3 is right: scheduled analgesia, hydration, warmth, and lung expansion together treat pain and prevent acute chest syndrome. Why 1 is wrong: cold promotes sickling and worsens occlusion. Why 2 is wrong: dehydration is a crisis trigger. Why 4 is wrong: withholding analgesia to re-verify a reported score is undertreatment. The rule: warm, hydrate, medicate, and keep the lungs open.

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Margin noteoozing from two sites at once is the tell.

Takeawayin this domain, partial-credit items reward knowing which laboratory values move together, not which single value is abnormal.

Coagulation reference ranges → BOOK 07 · P6.