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Hematology CCRN Practice Questions

10 free CCRN-style hematology practice questions with full rationales. Perfect for last-minute review or rapid drilling on high-yield concepts.

Question Index

  1. Q1: A patient on heparin for 7 days develops new thrombosis and a platelet count tha…
  2. Q2: The FIRST action when HIT is suspected is to:
  3. Q3: In DIC, which laboratory finding is the HALLMARK abnormality?
  4. Q4: The MOST important treatment priority in DIC is:
  5. Q5: Which blood product is indicated for a patient with DIC and fibrinogen level of …
  6. Q6: A patient with ITP has a platelet count of 8,000 and is bleeding. Which treatmen…
  7. Q7: The 4Ts score is used to assess probability of:
  8. Q8: Schistocytes on a peripheral blood smear in a critically ill patient suggest:
  9. Q9: TRALI (Transfusion-Related Acute Lung Injury) typically presents:
  10. Q10: Which anticoagulant is preferred as an alternative to heparin in confirmed HIT?
Question 1

A patient on heparin for 7 days develops new thrombosis and a platelet count that has dropped from 180,000 to 75,000. What is the MOST likely diagnosis?

  1. Immune thrombocytopenic purpura (ITP)
  2. Heparin-induced thrombocytopenia (HIT)
  3. Disseminated intravascular coagulation (DIC)
  4. Thrombotic thrombocytopenic purpura (TTP)

Correct Answer: B. Heparin-induced thrombocytopenia (HIT)

Rationale: HIT is characterized by thrombocytopenia (platelet drop ≥50% and count <100,000) AND thrombosis after heparin exposure, typically occurring 5-10 days after initiation. The paradox of HIT is that despite low platelets, patients develop CLOTS rather than bleeding. This differentiates it from ITP (bleeding risk) and DIC (both bleeding and clotting).
Question 2

The FIRST action when HIT is suspected is to:

  1. Transfuse platelets
  2. Start warfarin
  3. Discontinue ALL heparin products
  4. Administer vitamin K

Correct Answer: C. Discontinue ALL heparin products

Rationale: The FIRST action in suspected HIT is to STOP ALL HEPARIN immediately - including heparin flushes, heparin-coated catheters, and low molecular weight heparin. Platelet transfusions are contraindicated as they can worsen thrombosis. Warfarin should be held until platelets recover. An alternative anticoagulant like Argatroban should be started.
Question 3

In DIC, which laboratory finding is the HALLMARK abnormality?

  1. Elevated platelets
  2. Normal fibrinogen
  3. Elevated D-dimer with low fibrinogen and platelets
  4. Prolonged PT only

Correct Answer: C. Elevated D-dimer with low fibrinogen and platelets

Rationale: DIC is characterized by a constellation of findings: ELEVATED D-dimer and FDPs (from fibrinolysis), LOW fibrinogen (<100 mg/dL) and LOW platelets (<50,000) from consumption, and PROLONGED PT/aPTT from clotting factor depletion. All these abnormalities together distinguish DIC from other coagulopathies.
Question 4

The MOST important treatment priority in DIC is:

  1. Transfuse platelets immediately
  2. Administer heparin
  3. Treat the underlying cause
  4. Give FFP first

Correct Answer: C. Treat the underlying cause

Rationale: The MOST critical step in DIC management is treating the UNDERLYING CAUSE (sepsis, trauma, obstetric emergency, malignancy). Without addressing the trigger, the coagulation cascade continues to be activated. Blood product replacement (FFP, platelets, cryoprecipitate) is supportive but secondary to treating the inciting condition.
Question 5

Which blood product is indicated for a patient with DIC and fibrinogen level of 80 mg/dL?

  1. Packed red blood cells
  2. Fresh frozen plasma
  3. Cryoprecipitate
  4. Platelets

Correct Answer: C. Cryoprecipitate

Rationale: Cryoprecipitate is the blood product of choice for low fibrinogen (<100 mg/dL). It contains concentrated fibrinogen, factor VIII, factor XIII, and von Willebrand factor. FFP contains clotting factors but has lower fibrinogen concentration. A typical dose is 10 units of cryoprecipitate to raise fibrinogen by approximately 50 mg/dL.
Question 6

A patient with ITP has a platelet count of 8,000 and is bleeding. Which treatment is MOST appropriate?

  1. Heparin infusion
  2. Platelet transfusion, IVIG, and steroids
  3. Fresh frozen plasma only
  4. Vitamin K administration

Correct Answer: B. Platelet transfusion, IVIG, and steroids

Rationale: ITP with active bleeding and severely low platelets requires platelet transfusions (despite rapid destruction), IVIG (to temporarily block platelet destruction), and high-dose steroids (to reduce antibody production). Unlike HIT, platelet transfusions ARE indicated in ITP when there is active bleeding or very low counts.
Question 7

The 4Ts score is used to assess probability of:

  1. DIC
  2. ITP
  3. HIT
  4. TTP

Correct Answer: C. HIT

Rationale: The 4Ts score is used to assess the probability of Heparin-Induced Thrombocytopenia (HIT). The 4Ts include: Thrombocytopenia (degree and nadir), Timing of platelet fall, Thrombosis or other sequelae, and oTher causes of thrombocytopenia. A low score can help rule out HIT, while a high score warrants empirical treatment and testing.
Question 8

Schistocytes on a peripheral blood smear in a critically ill patient suggest:

  1. Iron deficiency anemia
  2. Vitamin B12 deficiency
  3. Microangiopathic hemolytic anemia (DIC, TTP)
  4. Chronic disease anemia

Correct Answer: C. Microangiopathic hemolytic anemia (DIC, TTP)

Rationale: Schistocytes (fragmented RBCs) on peripheral smear indicate microangiopathic hemolytic anemia (MAHA). They result from RBCs being sheared as they pass through fibrin strands in small vessels. This is seen in DIC, TTP/HUS, malignant hypertension, and mechanical heart valves. Their presence in a critically ill patient should raise suspicion for DIC.
Question 9

TRALI (Transfusion-Related Acute Lung Injury) typically presents:

  1. 24-48 hours after transfusion with gradual respiratory decline
  2. Within 6 hours of transfusion with acute hypoxemia and bilateral infiltrates
  3. Immediately with urticaria and bronchospasm
  4. 1 week after transfusion with fever

Correct Answer: B. Within 6 hours of transfusion with acute hypoxemia and bilateral infiltrates

Rationale: TRALI presents within 6 hours of transfusion with acute respiratory distress, hypoxemia, and bilateral pulmonary infiltrates on chest X-ray (similar to ARDS). It is caused by donor antibodies activating recipient neutrophils in the pulmonary vasculature. Treatment is supportive with oxygen and possible mechanical ventilation. It is a leading cause of transfusion-related mortality.
Question 10

Which anticoagulant is preferred as an alternative to heparin in confirmed HIT?

  1. Warfarin
  2. Aspirin
  3. Argatroban
  4. Enoxaparin

Correct Answer: C. Argatroban

Rationale: Argatroban (a direct thrombin inhibitor) is the preferred alternative anticoagulant in HIT. It does not cross-react with HIT antibodies. Warfarin is held initially because it can cause skin necrosis and venous limb gangrene in acute HIT. Enoxaparin (LMWH) is contraindicated due to cross-reactivity with HIT antibodies. Other options include bivalirudin and fondaparinux.

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