A nurse is caring for a 60-year-old patient with acute leukemia who is receiving chemotherapy. The patient reports severe fatigue and shortness of breath. Which assessment finding would be most concerning and require immediate intervention?
1Blood pressure 88/52 mmHg with heart rate 118 bpm after receiving IV morphine 30 minutes ago✓ 정답
2Patient reports nausea and has vomited twice in the past hour
3Oral temperature of 100.8°F (38.2°C) with mild chills
4White blood cell count of 2,500/mm³ from morning laboratory results
해설
Hypotension and tachycardia after IV morphine indicate cardiovascular compromise requiring immediate assessment and intervention. Other findings like nausea, fever, or low WBC are concerning but less urgent in this context.
Clinical Judgment
This question assesses Recognize Cues and Prioritize Hypotheses. The most immediate risk in a patient receiving chemotherapy for acute leukemia is hypotension and tachycardia. These symptoms appearing after IV morphine administration could be early signs of Opioid-induced hypotension or Anaphylaxis, with a risk of rapid progression to shock. Patients receiving chemotherapy are especially vulnerable to dehydration or infection, making hemodynamic instability even more dangerous.
Memory Tip: Remember the "ABCs." Prioritize in the order of Airway, Breathing, Circulation. Pain of 9/10 is severe, but a blood pressure of 88/52 mmHg and a heart rate of 118 bpm pose a direct threat to Circulation.
KR vs US: In Korea, there may be a tendency toward relatively conservative opioid use for pain management, but in NGN/US nursing, respecting the patient's self-reported pain while emphasizing systematic monitoring for drug side effects is strongly highlighted. Specifically, checking vital signs within 30 minutes after the initial dose is standard protocol.
Clinical Practice Guide
When administering IV opioids (especially morphine), closely monitor vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation) and level of consciousness for the first 15–30 minutes. If hypotension occurs, stop the infusion immediately, position the patient comfortably flat, check/increase the IV fluid rate, and report to the responsible healthcare professional (HCP).
Caution: In SATA (Select All That Apply) questions, when asked to choose the "most concerning" finding, base your judgment on direct and immediate threats to life. Vomiting or low-grade fever are important but have a lower priority than signs of circulatory collapse.
Hypotension — A condition where blood pressure falls below the normal range. It generally means a systolic blood pressure under 90 mmHg and may be an early sign of shock.
Tachycardia — A state where the resting heart rate increases above the normal range (typically 100 bpm for adults). It can occur as a compensatory mechanism for pain, anxiety, dehydration, bleeding, shock, etc.
Opioid-induced Hypotension — Hypotension caused by opioid analgesics inducing vasodilation, histamine release, or decreased cardiac output. It can occur particularly rapidly with IV administration, requiring careful monitoring.
Neutropenia — Neutrophil count is abnormally low (typically <1,500/mm³). It is a common side effect of chemotherapy and significantly increases the risk of serious infection.
Neutropenic Fever — In patients with neutropenia, a single fever measurement of 100.4°F (38.0°C) or higher. This is considered an emergency, and empirical antibiotic therapy should be started without delay.