A nurse is caring for a client with stage IV small cell lung cancer who is receiving chemotherapy and has fatigue, shortness of breath, and a white blood cell count of 2,000/mm³. Which nursing intervention should be the priority to prevent the most life-threatening complication?

The client is experiencing fatigue, shortness of breath, and has a white blood cell count of 2,000/mm³.

1 Encourage increased fluid intake to prevent dehydration
2 Provide emotional support and counseling resources
3 Implement strict infection control precautions and monitor for signs of infection ✓ 정답
4 Administer prescribed antiemetics to prevent nausea and vomiting

해설

Implementing strict infection control is the priority due to neutropenia (WBC 2,000/mm³), which poses a high risk for life-threatening infection. Other interventions are important but address less immediate threats.

같은 주제 다음 문제A nurse is assessing a 65-year-old client with suspected lung cancer. Which assessment fin…

심화 해설

Understanding the Priority: Life-Threatening Complication in Neutropenia

For a client with stage IV small cell lung cancer undergoing chemotherapy, the reported white blood cell (WBC) count of 2,000/mm³ indicates severe immunosuppression. While the absolute neutrophil count (ANC) is the most specific marker, a WBC this low strongly correlates with profound neutropenia (typically defined as an ANC

임상 시나리오

Neutropenic PrecautionsPreventing Sepsis in Immunosuppressed Clients

A WBC count of 2,000/mm³ indicates severe immunosuppression. The priority is strict infection control to prevent sepsis, the most life-threatening complication.

Implement protective isolation with strict hand hygiene. Monitor for subtle signs of infection, as the typical inflammatory response (redness, pus) may be absent. A fever of 38.0°C (100.4°F) or higher is a medical emergency.

Caution

Avoid rectal temperatures, suppositories, and enemas to prevent mucosal tears. No fresh flowers or raw foods. Immediate antibiotic administration is critical once cultures are drawn.

핵심 개념

Neutropenia — An abnormally low count of neutrophils, a type of white blood cell that helps fight infection, often a side effect of chemotherapy.
Immunosuppression — Reduction in the activation or efficacy of the immune system, increasing susceptibility to opportunistic infections.
Absolute Neutrophil Count (ANC) — A calculation of the actual number of neutrophils in a blood sample, used to assess infection risk; severe neutropenia is typically ANC < 500/mm³.
Small Cell Lung Cancer — An aggressive form of lung cancer strongly associated with smoking, often treated with chemotherapy due to its rapid growth and early metastasis.

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A nurse is caring for a client with stage IV small cell lung cancer who is receiving chemotherapy and has fatigue, shortness of breath, and a white blood cell count of 2,000/mm³. Which nursing intervention should be the priority to prevent the most life-threatening complication?

심화 해설

임상 시나리오

핵심 개념

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