Chemotherapy

A nurse is caring for a client with advanced ovarian cancer who is receiving palliative chemotherapy. The client reports severe fatigue, shortness of breath, and dizziness. Laboratory results show hemoglobin 6.2 g/dL, hematocrit 18%, and platelet count 45,000/mm³. What is the priority nursing intervention?

The client with pancreatic cancer is experiencing severe bone marrow suppression from chemotherapy, requiring immediate nursing assessment and intervention to prevent life-threatening complications.

1 Administer oxygen therapy at 2 L/min via nasal cannula
2 Prepare the client for blood transfusion as ordered ✓ 정답
3 Encourage increased fluid intake to prevent dehydration
4 Implement fall precautions and activity restrictions

해설

Severe anemia (Hb 6.2 g/dL) and thrombocytopenia require immediate blood transfusion to prevent cardiovascular collapse and bleeding. Other interventions are supportive but do not address the underlying life-threatening condition.

같은 주제 다음 문제A nurse is caring for a client with stage IV pancreatic cancer who has been receiving chem…이 문제가 수록된 문제집[개념+기출] 엔클렉스(NCLEX), 이거 하나면 됩니다69,000원

Understanding the Clinical Picture
The client’s laboratory values reveal pancytopenia secondary to chemotherapy-induced bone marrow suppression. The hemoglobin of 6.2 g/dL and hematocrit of 18% indicate severe symptomatic anemia, which directly explains the fatigue, shortness of breath, and dizziness. The platelet count of 45,000/mm³ signifies severe thrombocytopenia, placing the client at high risk for spontaneous or life-threatening bleeding ^[1].

Prioritizing Interventions Using the ABC Framework
In NCLEX-RN prioritization, physiological needs are addressed using the airway, breathing, and circulation (ABC) framework, with an emphasis on acute threats to circulatory volume and oxygen-carrying capacity. While administering oxygen (Option 1) may temporarily improve dyspnea, it does not correct the underlying deficit in oxygen-carrying capacity caused by critically low red blood cell mass. The client’s dizziness and shortness of breath are primarily due to impaired tissue oxygenation from severe anemia, not a primary pulmonary problem. The most direct and definitive intervention to restore circulatory oxygen delivery is to increase the hemoglobin level. Therefore, preparing for a packed red blood cell transfusion (Option 2) is the priority action to correct the cause of the symptoms and prevent progression to hypovolemic or anemic shock.

The Critical Risk of Bleeding in Malignancy
The profound thrombocytopenia elevates the risk of bleeding, a concern that is significantly amplified in patients with active malignancy. As highlighted in the provided evidence, patients with cancer have a multifactorial bleeding risk that extends beyond a single laboratory value. Tumor-related vascular fragility, impaired hepatic function, malnutrition, and systemic inflammation all contribute to a compromised hemostatic balance ^[1]. In this scenario, a seemingly minor event, such as a stumble, could lead to a catastrophic hemorrhage, including a spontaneous retroperitoneal or iliacus muscle hematoma, as documented in the literature ^[1]. This understanding reinforces why implementing fall precautions (Option 4) is a critical secondary intervention, but it is not the priority over a treatment that directly addresses the immediate, symptomatic, life-threatening anemia. Encouraging fluids (Option 3) is inappropriate and could precipitate fluid volume overload without correcting the anemia.

Clinical Reasoning and Safe Practice
The nurse’s immediate action must target the most acute threat to life. The sequence of clinical reasoning is: recognize that the severe anemia is causing the client’s acute symptoms, understand that a transfusion directly and rapidly reverses this threat by restoring oxygen-carrying capacity, and simultaneously recognize that the severe thrombocytopenia makes any delay in stabilizing the client dangerous due to the risk of spontaneous bleeding ^[1]. After preparing for and initiating the transfusion, the nurse would then implement fall precautions and activity restrictions to mitigate the bleeding risk associated with thrombocytopenia.

References (research sources)

[1]
Non-traumatic Iliacus Muscle Hematoma During Anticoagulation Bridging in a Patient With Active Malignancy: A Case of Multifactorial Bleeding Risk.Case reportFernandez Perez S, Sosa FA, Chong RW. (2026) · DOI: 10.7759/cureus.109221

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