A nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Which nursing intervention is the priority to prevent complications?
A 28-year-old client with stage II Hodgkin's lymphoma is receiving ABVD chemotherapy (Adriamycin, Bleomycin, Vinblastine, Dacarbazine). The client's current laboratory values show: WBC 2,800/mm³, ANC 1,200/mm³, platelets 85,000/mm³, and hemoglobin 9.2 g/dL.
1Implement strict neutropenic precautions and monitor for signs of infection✓ 정답
2Encourage increased fluid intake to prevent dehydration
3Administer antiemetics as needed for nausea and vomiting
4Provide emotional support and counseling for body image changes
해설
The priority is implementing strict neutropenic precautions due to the low WBC and ANC, which indicate high infection risk. Other interventions address less immediate threats.
This client presents with laboratory values that immediately signal a critical safety concern. The absolute neutrophil count (ANC) is 1,200/mm³, which falls below the threshold of 1,500 cells/μL that defines neutropenia[1]. While this is classified as mild neutropenia, the combination with a low total white blood cell count (2,800/mm³) and thrombocytopenia (85,000/mm³) indicates significant bone marrow suppression from the ABVD chemotherapy regimen. In the hierarchy of nursing priorities, physiological safety—specifically protection from life-threatening infection—takes precedence. Febrile neutropenia (FN) is identified as one of the most serious yet potentially preventable complications of systemic chemotherapy, and early nursing-led risk stratification is essential to improving outcomes [2].
Why Infection Prevention Is the Priority
The pathophysiology of chemotherapy-induced neutropenia involves the cytotoxic effects of agents like Adriamycin and Vinblastine on rapidly dividing hematopoietic stem cells in the bone marrow. When the ANC drops, the body's first line of defense against bacterial and fungal pathogens is compromised. A patient with an ANC below 1,000/mm³ faces a markedly increased risk of developing febrile neutropenia, a condition where the only sign of overwhelming infection may be a single temperature spike. Nursing interventions grounded in strict infection control—such as meticulous hand hygiene, environmental cleaning, and the use of risk assessment tools—are foundational to clinical management [1]. A personalized nursing pathway for infection prevention has been shown to significantly reduce hospital-acquired infections in immunocompromised hematology patients, validating this as the highest-priority action [4].
Analysis of Alternative Options
Encouraging fluid intake is a supportive measure to manage potential dehydration from chemotherapy side effects, but it does not address the most immediate threat to physiological integrity. Administering antiemetics is important for comfort and nutritional status, yet nausea control is secondary to preventing a systemic infection that could lead to sepsis. Providing emotional support and counseling for body image changes addresses the psychosocial domain, which, while integral to holistic care, is not the priority when a life-threatening physiological risk is present. Evidence-based nursing strategies do incorporate psychosocial support—interventions like telehealth and Managing Cancer And Living Meaningfully therapy can reduce distress by 38-45%—but these are implemented alongside, not before, strict infection control measures [1].
Clinical Implementation of Neutropenic Precautions
Implementing strict neutropenic precautions involves a multi-domain approach. Clinically, the nurse must monitor vital signs every 4 hours, immediately report any temperature of 38.0°C (100.4°F) or higher, inspect skin and mucous membranes for breaks in integrity, and ensure no rectal temperatures or invasive procedures are performed. Patient education is a powerful tool: competency-based training and mHealth tools have been shown to improve adherence to infection prevention protocols by 42%[1]. The nurse should teach the client to avoid crowds, fresh flowers, and raw foods, while emphasizing meticulous oral care. A nursing risk prediction model for febrile neutropenia enables bedside nurses to use readily assessable clinical variables to stratify risk and trigger preventive actions before a fever develops, reinforcing why proactive infection monitoring is the priority intervention [2]. The presence of thrombocytopenia further supports this choice, as an infection could necessitate invasive procedures or antibiotic therapy that carry additional bleeding risks.
References (research sources)
[1]
Optimizing nursing care for neutropenic patients: a holistic perspective on education, support, and clinical management.Research articleXu ZN, Gao LP, Wang XK, Yu XL, Cong Y, Wang PJ. (2025) · DOI: 10.3389/fmed.2025.1633708
[2]
Development and clinical validation of a nursing risk prediction model for chemotherapy-induced febrile neutropenia in patients with cancer.Research articleXie F, Zheng D, Chen N, Zhang J, Wang N, Yi Q, Wang L. (2026) · DOI: 10.3389/fcell.2026.1779406
[4]
Application of a Personalized Nursing Pathway for Infection Prevention in Hospitalized Leukemia Patients: A Single-Center Retrospective Cohort Study.Research articleLin J, Guo Q, Zhuang P, Xie X, Zheng R, Chen X. (2025) · DOI: 10.2147/tcrm.s550531
Neutropenic Precautions for Chemotherapy PatientsImmediate nursing actions when ANC is low
The absolute neutrophil count (ANC) of 1,200/mm³ indicates mild neutropenia. The priority is strict infection prevention because the body's primary defense against pathogens is compromised.
Implement strict hand hygiene for all staff and visitors. Ensure the client is in a private room and that no fresh flowers or standing water are present. Monitor vital signs every 4 hours, with immediate reporting for a single temperature of ≥38.0°C (100.4°F).
Caution
In a neutropenic client, a fever may be the only sign of a life-threatening infection. Do not administer antipyretics without a prescriber's order, as they can mask this critical sign. Promptly initiate the sepsis protocol if febrile neutropenia is suspected.
호중구감소증 — A condition where the Absolute Neutrophil Count (ANC) is below 1,500/mm³. It is a major complication of chemotherapy, posing a serious risk of infection.
호지킨 림프종 (Hodgkin's Lymphoma) — A malignant tumor of the lymphatic system, characterized by Reed-Sternberg cells. It primarily occurs in young adults, and ABVD chemotherapy is one of the standard treatments.
ABVD 화학요법 — Chemotherapy combination used for first-line treatment of Hodgkin lymphoma. It consists of four drugs: Adriamycin, Bleomycin, Vinblastine, and Dacarbazine, and can cause various side effects including bone marrow suppression.
절대호중구수 (Absolute Neutrophil Count, ANC) — The actual number of neutrophils fighting infection in the body. It is calculated using the WBC count and neutrophil percentage. This is the most important indicator for assessing infection risk.
보호격리 (Reverse Isolation/Protective Isolation) — A method of isolation to protect immunocompromised patients, such as those with neutropenia, from pathogens in the external environment. The goal is to prevent healthy individuals from transmitting pathogens to the patient.