# A client who underwent an allogeneic stem cell transplant two weeks ago remains in a protective isolation unit while awaiting engraftment. Which assessment finding is the highest priority for the nurse to address immediately?

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> subject: Adult Health

## 문제

A client who underwent an allogeneic stem cell transplant two weeks ago remains in a protective isolation unit while awaiting engraftment. Which assessment finding is the highest priority for the nurse to address immediately?

## 보기

1. Temperature of 101.2°F (38.4°C) with rigors and chills **✔ 정답**
2. Platelet count of 25,000/μL with petechiae on lower extremities
3. White blood cell count of 1,200/μL with 60% neutrophils
4. Hemoglobin level of 8.5 g/dL with mild fatigue

**정답: 1**

## 해설

Fever with rigors and chills in a post-transplant patient indicates potential infection, which is life-threatening during neutropenia and requires immediate intervention. Other findings like thrombocytopenia, leukopenia, and anemia are expected and managed with supportive care.

## 심화 해설

Clinical Context and Priority Setting

This client is in the pre-engraftment phase following an allogeneic stem cell transplant, a period of profound immunosuppression. The immediate priority is to identify the finding that indicates a life-threatening condition requiring urgent intervention. In this immunocompromised state, the development of a new fever with rigors is a clinical emergency representing potential septic physiology until proven otherwise.

Analysis of the Correct Answer (Option 1)

A temperature of 101.2°F (38.4°C) accompanied by rigors and chills is the highest priority. This presentation is the classic clinical manifestation of febrile neutropenia with a high likelihood of a bloodstream infection (BSI). The rigors indicate the release of inflammatory cytokines in response to a significant bacterial load entering the bloodstream. In the post-allogeneic transplant population, the risk of rapid clinical deterioration from sepsis is extreme. The provided evidence underscores that febrile neutropenia develops in approximately three-quarters of allo-HSCT recipients, and infections with resistant organisms such as carbapenem-resistant Enterobacterales (CRE) can carry a mortality rate reaching 70% [1]. The presence of rigors is a strong clinical indicator of a high-risk infectious process, and guidelines mandate immediate blood cultures and the administration of empiric broad-spectrum antibiotics within one hour of presentation. The research on risk prediction models for BSI in stem cell transplant patients further validates that fever in this context is a primary driver of urgent clinical decision-making to prevent overwhelming sepsis .

Analysis of Incorrect Answers

Option 2. A platelet count of 25,000/μL with petechiae indicates severe thrombocytopenia and a risk of spontaneous bleeding. While this requires close monitoring and likely a platelet transfusion based on institutional protocols, it does not represent the same immediate, minute-to-minute threat to life as septic shock. The risk of a fatal intracranial hemorrhage, while serious, is a slower-developing crisis compared to the rapid cardiovascular collapse possible with gram-negative bacteremia.

Option 3. A white blood cell count of 1,200/μL with 60% neutrophils results in an absolute neutrophil count (ANC) of 720/μL. This is an expected finding in the pre-engraftment phase and, importantly, does not meet the criteria for severe neutropenia (ANC < 500/μL). The referenced prospective validation of risk prediction models specifically addresses the management of febrile patients without severe neutropenia (ANC ≥ 500/μL), acknowledging that this lab value alone, in the absence of fever, does not trigger the same emergent sepsis protocol as febrile neutropenia .

Option 4. A hemoglobin level of 8.5 g/dL with mild fatigue reflects symptomatic anemia, which is common after conditioning chemotherapy. The symptom of "mild fatigue" indicates the patient is physiologically compensating and stable. While a red blood cell transfusion may be indicated, this is a supportive care measure that is prioritized below the immediate threat of an untreated bloodstream infection, where a delay in antibiotic administration is directly linked to increased mortality [1].References (research sources)

- [1]Empiric Imipenem/Cilastatin/Relebactam for Febrile Neutropenia After Allogeneic Hematopoietic Stem Cell Transplantation: Two Case Reports.Case reportDeng DX, Wang T, Sun H, Kong J, Zhang YY, Cao LQ, Mo XD. (2026) · DOI: 10.2147/jbm.s565949

## 임상 시나리오

Febrile Neutropenia in Post-Transplant PatientImmediate Recognition and Management of Sepsis
A single temperature of 38.3°C (101°F) or higher in a patient with an absolute neutrophil count (ANC) <500/μL constitutes a medical emergency. The presence of rigors strongly suggests a high bacterial load and impending hemodynamic instability.

Immediate priorities include obtaining blood cultures (peripheral and from any central line) and administering empiric broad-spectrum antibiotics within 60 minutes of fever documentation. Do not delay antibiotics for culture collection if it is logistically difficult.

CautionIn the pre-engraftment phase, the absence of neutrophils means the patient may lack typical signs of localized infection (pus, erythema). A fever with rigors is often the only early sign of a life-threatening bloodstream infection with organisms like gram-negative rods, which can carry a mortality rate exceeding 70% if treatment is delayed.

## 핵심 개념

- **Allogeneic Stem Cell Transplant** — A procedure where a patient receives blood-forming stem cells from a genetically similar, but not identical, donor to treat various cancers and bone marrow failure syndromes.
- **Engraftment** — The process where transplanted stem cells begin to grow and produce new blood cells in the bone marrow, typically occurring 2-4 weeks post-transplant.
- **Febrile Neutropenia** — A medical emergency defined as a single oral temperature of ≥38.3°C (101°F) or a sustained temperature of ≥38.0°C (100.4°F) over 1 hour, in a patient with an absolute neutrophil count (ANC)
- **Rigors** — Severe, uncontrollable shaking chills accompanied by a rapid rise in body temperature, often indicating a significant release of bacteria or endotoxins into the bloodstream.

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