Leukemia

The nurse is monitoring a client with acute lymphoblastic leukemia during chemotherapy treatment. Which assessment finding requires the most immediate nursing intervention?

1 White blood cell count of 2,000/mm³
2 Platelet count of 50,000/mm³
3 Temperature of 101.2°F (38.4°C) with chills ✓ 정답
4 Hemoglobin level of 8.5 g/dL

해설

Fever with chills in a neutropenic patient indicates potential sepsis requiring immediate intervention with blood cultures and antibiotics. Other findings (low WBC, platelets, hemoglobin) are concerning but less urgent.

같은 주제 다음 문제A nurse is assessing a 28-year-old patient with acute lymphoblastic leukemia (ALL) who was…이 문제가 수록된 문제집[개념+기출] 엔클렉스(NCLEX), 이거 하나면 됩니다69,000원

Clinical Priority in Febrile Neutropenia

In a client with acute lymphoblastic leukemia (ALL) undergoing chemotherapy, the assessment finding that requires the most immediate nursing intervention is a temperature of 101.2°F (38.4°C) with chills. This presentation signifies febrile neutropenia, a critical oncologic emergency where the body’s ability to mount an inflammatory response is severely compromised, making a seemingly simple fever a harbinger of life-threatening sepsis.

The rationale is rooted in the pathophysiology of chemotherapy-induced bone marrow suppression. Cytotoxic agents destroy rapidly dividing cells, including the hematopoietic stem cells responsible for producing neutrophils. Neutropenia, typically defined as an absolute neutrophil count (ANC) below 500/mm³, leaves the client without the primary cellular defense against bacterial and fungal organisms. In this immunocompromised state, the host cannot effectively localize or contain an infection. A fever, therefore, is often the only initial sign of a bloodstream infection that can rapidly progress to septic shock and death within hours if antimicrobial therapy is delayed. The provided evidence underscores that febrile neutropenia is a frequent and potentially life-threatening complication in patients with hematologic malignancies, requiring prompt and accurate identification of pathogens to optimize therapy and improve outcomes ^[1].

While the other laboratory values represent significant clinical derangements requiring intervention, they do not carry the same immediate, time-sensitive threat of mortality as a fever in a neutropenic host. A white blood cell count of 2,000/mm³ indicates leukopenia and increased infection risk, but it is the presence of fever that signals an active, systemic process. A platelet count of 50,000/mm³ places the client at risk for spontaneous bleeding, such as intracranial hemorrhage, which is a critical concern, yet it typically does not demand intervention within the same 30-to-60-minute window as a septic source. Similarly, a hemoglobin level of 8.5 g/dL reflects moderate anemia that can impair oxygenation and cause fatigue, but the body’s compensatory mechanisms generally allow for a more controlled response with transfusion. The clinical priority is dictated by the "ABC" (Airway, Breathing, Circulation) framework and the immediate threat to circulation from sepsis-induced vasodilation and capillary leak. The standard of care mandates that any fever in a neutropenic patient is treated as a medical emergency, requiring immediate collection of blood cultures and administration of broad-spectrum intravenous antibiotics, ideally within one hour of presentation.

References (research sources)

[1]
Diagnostic performance of the Sepsis qPCR MX-30^® panel compared with conventional blood culture in pediatric febrile neutropenia: a single-center retrospective study.Research articleKurtipek FB, Yozgat AK, Gökçek E, Kaçar D, Dinç B, Yaralı N. (2026) · DOI: 10.1186/s12879-026-13352-0

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The nurse is monitoring a client with acute lymphoblastic leukemia during chemotherapy treatment. Which assessment finding requires the most immediate nursing intervention?

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