# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=540630  
> language: ko  
> subject: Adult Health

## 문제

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?

## 보기

1. Blood pressure 88/52 mmHg with heart rate 118 bpm after receiving IV morphine 30 minutes ago **✔ 정답**
2. Patient reports nausea and has vomited twice in the past hour
3. Oral temperature of 100.8°F (38.2°C) with mild chills
4. White blood cell count of 2,500/mm³ from morning laboratory results

**정답: 1**

## 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.

## 심화 해설

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.

## 임상 시나리오

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.

## 핵심 개념

- **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
- **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.

## 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)
- [The nurse is assessing a patient with acute leukemia experiencing severe bone pain during …](https://mymerci.kr/pages/nclex_q.php?qn_id=540627)
- [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 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._