# The nurse is assessing a patient with acute leukemia experiencing severe bone pain during chemotherapy treatment. The patient reports severe bone pain rated 9/10 on the pain scale. Which assessment finding would be most concerning and require immediate nursing intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=540627  
> language: ko  
> subject: Adult Health

## 문제

The nurse is assessing a patient with acute leukemia experiencing severe bone pain during chemotherapy treatment. The patient reports severe bone pain rated 9/10 on the pain scale. Which assessment finding would be most concerning and require immediate nursing intervention?

## 보기

1. Patient reports nausea and has vomited twice in the past hour
2. Patient's vital signs show BP 88/52 mmHg, HR 118 bpm, and temperature 101.8°F (38.8°C) **✔ 정답**
3. Patient states the pain medication is not providing adequate relief
4. Patient appears anxious and is asking frequent questions about the treatment

**정답: 2**

## 해설

Hypotension, tachycardia, and fever in a chemotherapy patient indicate potential sepsis or neutropenic fever, which requires immediate intervention.

This question assesses a nurse's ability to prioritize complications in an oncology patient receiving chemotherapy. The correct answer focuses on recognizing signs of sepsis or neutropenic fever, which are life-threatening emergencies in immunocompromised patients.

Patients receiving chemotherapy for acute leukemia are at very high risk for neutropenia due to suppressed white blood cell production. When the neutrophil count drops to 1,000/mm³ or below, the patient becomes severely immunocompromised and vulnerable to overwhelming infection. The combination of hypotension (88/52 mmHg), tachycardia (118 bpm), and fever (101.8°F) represents the classic triad of septic shock or neutropenic fever.

Neutropenic fever is defined in a neutropenic patient as a single oral temperature of ≥100.4°F (38°C) or a sustained temperature of ≥100.4°F for over one hour. Hemodynamic instability, manifested by hypotension and compensatory tachycardia, suggests the patient may be progressing to septic shock, which carries a high mortality rate if not treated immediately.

The nursing priority is to recognize these signs as a medical emergency, immediately notify the physician, obtain blood cultures, and rapidly administer broad-spectrum antibiotics. Delays in treatment can lead to rapid clinical deterioration and death. Bone pain is an expected symptom in leukemia patients and causes significant discomfort, but hemodynamic instability with fever represents an immediate life threat and takes absolute priority.

## 심화 해설

Clinical Reasoning and Priority Setting

When caring for a patient with acute leukemia who is receiving chemotherapy and reports severe bone pain, the nurse must rapidly differentiate between expected treatment side effects and life-threatening complications. The assessment finding that is most concerning and demands immediate intervention is the combination of hypotension, tachycardia, and fever.

Analysis of the Most Concerning Finding

The vital signs showing a blood pressure of 88/52 mmHg, a heart rate of 118 bpm, and a temperature of 101.8°F (38.8°C) represent a classic clinical triad for a critical oncologic emergency: neutropenic sepsis. In a patient with acute leukemia undergoing myelosuppressive chemotherapy, the bone marrow's ability to produce functional neutrophils is severely compromised, leading to profound neutropenia. The presence of fever in this context is a medical emergency because the patient lacks the immune defenses to contain even a minor infection. The hypotension and tachycardia indicate that the body's compensatory mechanisms are failing and the patient is progressing into septic shock with systemic vasodilation and potential capillary leak. This presentation aligns with the high-risk profile described in the literature for invasive infections in immunocompromised patients, where persistent high-risk febrile neutropenia is a direct precursor to life-threatening conditions [4]. Immediate nursing interventions must include obtaining blood cultures, initiating broad-spectrum intravenous antibiotics within one hour of fever recognition, administering fluid resuscitation as prescribed, and closely monitoring for further hemodynamic deterioration.

Why the Other Options Are Lower Priority

While the other findings require nursing action, they do not represent an immediate threat to the patient's survival in the same way that septic shock does.

-   Nausea and vomiting (Option 1) are common and distressing side effects of chemotherapy. The nurse should administer prescribed antiemetics and provide comfort measures, but these symptoms are not immediately life-threatening.

-   Inadequate pain relief (Option 3) from bone pain is a significant comfort and quality-of-life issue. Leukemic infiltration of the bone marrow and the effects of chemotherapy can cause intense pain. The nurse should reassess the pain, consult the provider for a possible adjustment in the analgesic regimen, and employ non-pharmacological interventions. However, pain management, while crucial, is secondary to stabilizing hemodynamic instability.

-   Anxiety and frequent questions (Option 4) are expected psychological responses to a serious diagnosis and severe pain. The nurse should provide therapeutic communication, education, and emotional support. This psychosocial need is important but does not take precedence over a physiological crisis indicating possible sepsis.

The clinical picture of fever with hemodynamic instability in a neutropenic host points directly to a systemic infection that can rapidly become fatal without immediate, evidence-based intervention [4]. The nurse's priority is to recognize this as a sign of impending septic shock and act to restore tissue perfusion and combat the suspected infection.References (research sources)

- [4]Advancing the Identification of Risk Factors for Invasive Fungal Disease in Children with Cancer.Research articleBarraza M, Valenzuela R, Gutiérrez V, Greppi C, Álvarez AM, Cerda J, Santolaya ME. (2026) · DOI: 10.3390/jof12010060

## 임상 시나리오

Neutropenic Sepsis RecognitionThe Triad of Fever, Hypotension, and Tachycardia
In a patient with acute leukemia on chemotherapy, any fever of 38.3°C (101°F) or higher is a medical emergency. The combination of fever with hypotension (88/52 mmHg) and tachycardia (118 bpm) indicates progression to septic shock, a life-threatening condition requiring immediate intervention.

The priority nursing action is to initiate the sepsis protocol: obtain blood cultures from two different sites (including a central line if present), administer the first dose of a broad-spectrum IV antibiotic within 1 hour of fever recognition, and start IV fluid resuscitation as ordered.

CautionDo not delay antibiotic administration for a full sepsis workup. A rectal temperature measurement, enemas, and intramuscular injections are contraindicated in neutropenic patients due to the risk of mucosal tearing and infection introduction.

## 핵심 개념

- **Neutropenic Sepsis** — A life-threatening condition in patients with low neutrophil counts (often from chemotherapy) where fever and signs of systemic infection progress to organ dysfunction and shock.
- **Septic Shock** — A subset of sepsis with profound circulatory and metabolic abnormalities, characterized by persistent hypotension requiring vasopressors and elevated lactate levels despite fluid resuscitation.
- **Febrile Neutropenia** — A medical emergency defined as a single oral temperature ≥38.3°C (101°F) or a sustained temperature ≥38°C (100.4°F) over 1 hour in a patient with an absolute neutrophil count (ANC)
- **Myelosuppression** — A condition where bone marrow activity is decreased, resulting in reduced production of blood cells (red cells, white cells, and platelets), a common side effect of chemotherapy.

## 같은 주제 문제

- [A nurse is caring for a 40-year-old patient with acute leukemia who is experiencing severe…](https://mymerci.kr/pages/nclex_q.php?qn_id=540625)
- [A nurse is caring for a patient with acute leukemia who is experiencing severe bone pain r…](https://mymerci.kr/pages/nclex_q.php?qn_id=540626)
- [A nurse is caring for a 51-year-old patient with acute leukemia who is receiving chemother…](https://mymerci.kr/pages/nclex_q.php?qn_id=540628)
- [A nurse is assessing a 45-year-old patient with acute myeloid leukemia who has been receiv…](https://mymerci.kr/pages/nclex_q.php?qn_id=540629)
- [A nurse is caring for a 60-year-old patient with acute leukemia who is receiving chemother…](https://mymerci.kr/pages/nclex_q.php?qn_id=540630)
- [A nurse is caring for a client with bone metastases from breast cancer who is experiencing…](https://mymerci.kr/pages/nclex_q.php?qn_id=540631)
- [A nurse is caring for a patient with acute leukemia who is experiencing severe bone pain r…](https://mymerci.kr/pages/nclex_q.php?qn_id=540632)
- [A nurse is caring for a 45-year-old patient with acute leukemia who is receiving chemother…](https://mymerci.kr/pages/nclex_q.php?qn_id=540633)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._