# The nurse is monitoring a client with acute lymphoblastic leukemia during chemotherapy treatment. Which assessment finding requires the most immediate nursing intervention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=540676  
> language: ko  
> subject: Adult Health

## 문제

The nurse is monitoring a client with acute lymphoblastic leukemia during chemotherapy treatment. Which assessment finding requires the most immediate nursing intervention?

## 보기

1. White blood cell count of 2,000/mm³
2. Platelet count of 50,000/mm³
3. Temperature of 101.2°F (38.4°C) with chills **✔ 정답**
4. Hemoglobin level of 8.5 g/dL

**정답: 3**

## 해설

Fever with chills in a neutropenic patient indicates potential sepsis requiring immediate intervention with blood cultures and antibiotics. Other findings (low WBC, platelets, hemoglobin) are concerning but less urgent.

## 심화 해설

Clinical Priority in Febrile Neutropenia

In a client with acute lymphoblastic leukemia (ALL) undergoing chemotherapy, the assessment finding that requires the most immediate nursing intervention is a temperature of 101.2°F (38.4°C) with chills. This presentation signifies febrile neutropenia, a critical oncologic emergency where the body’s ability to mount an inflammatory response is severely compromised, making a seemingly simple fever a harbinger of life-threatening sepsis.

The rationale is rooted in the pathophysiology of chemotherapy-induced bone marrow suppression. Cytotoxic agents destroy rapidly dividing cells, including the hematopoietic stem cells responsible for producing neutrophils. Neutropenia, typically defined as an absolute neutrophil count (ANC) below 500/mm³, leaves the client without the primary cellular defense against bacterial and fungal organisms. In this immunocompromised state, the host cannot effectively localize or contain an infection. A fever, therefore, is often the only initial sign of a bloodstream infection that can rapidly progress to septic shock and death within hours if antimicrobial therapy is delayed. The provided evidence underscores that febrile neutropenia is a frequent and potentially life-threatening complication in patients with hematologic malignancies, requiring prompt and accurate identification of pathogens to optimize therapy and improve outcomes [1].

While the other laboratory values represent significant clinical derangements requiring intervention, they do not carry the same immediate, time-sensitive threat of mortality as a fever in a neutropenic host. A white blood cell count of 2,000/mm³ indicates leukopenia and increased infection risk, but it is the presence of fever that signals an active, systemic process. A platelet count of 50,000/mm³ places the client at risk for spontaneous bleeding, such as intracranial hemorrhage, which is a critical concern, yet it typically does not demand intervention within the same 30-to-60-minute window as a septic source. Similarly, a hemoglobin level of 8.5 g/dL reflects moderate anemia that can impair oxygenation and cause fatigue, but the body’s compensatory mechanisms generally allow for a more controlled response with transfusion. The clinical priority is dictated by the "ABC" (Airway, Breathing, Circulation) framework and the immediate threat to circulation from sepsis-induced vasodilation and capillary leak. The standard of care mandates that any fever in a neutropenic patient is treated as a medical emergency, requiring immediate collection of blood cultures and administration of broad-spectrum intravenous antibiotics, ideally within one hour of presentation.References (research sources)

- [1]Diagnostic performance of the Sepsis qPCR MX-30<sup>®</sup> panel compared with conventional blood culture in pediatric febrile neutropenia: a single-center retrospective study.Research articleKurtipek FB, Yozgat AK, Gökçek E, Kaçar D, Dinç B, Yaralı N. (2026) · DOI: 10.1186/s12879-026-13352-0

## 임상 시나리오

Febrile Neutropenia ManagementImmediate intervention for chemotherapy patients
In a patient with acute leukemia on chemotherapy, a single temperature of 38.3°C (101°F) or higher is an oncologic emergency. Fever is often the only sign of infection due to the absence of neutrophils needed to form pus or localize inflammation.

Immediate nursing actions include obtaining blood cultures (peripheral and from any central line), initiating broad-spectrum IV antibiotics within 1 hour of presentation, and administering antipyretics as ordered. Do not delay antibiotics for culture collection.

CautionAvoid rectal temperatures and suppositories due to the risk of mucosal bleeding and bacterial translocation in thrombocytopenic and neutropenic patients. Monitor closely for signs of septic shock such as hypotension and altered mental status.

## 핵심 개념

- **Febrile Neutropenia** — An oncologic emergency defined as a single oral temperature ≥38.3°C (101°F) or a sustained temperature ≥38.0°C (100.4°F) for over an hour in a patient with an absolute neutrophil count (ANC)
- **Absolute Neutrophil Count (ANC)** — A measure of the body's ability to fight bacterial infections; calculated as WBC × (% neutrophils + % bands). Severe neutropenia is an ANC
- **Acute Lymphoblastic Leukemia (ALL)** — A hematologic malignancy characterized by the overproduction of immature lymphoblasts in the bone marrow, leading to pancytopenia and increased infection risk.

## 같은 주제 문제

- [A nurse is assessing a 28-year-old patient with acute lymphoblastic leukemia (ALL) who was…](https://mymerci.kr/pages/nclex_q.php?qn_id=540669)
- [The nurse is conducting a comprehensive assessment of a 70-year-old patient with AML who h…](https://mymerci.kr/pages/nclex_q.php?qn_id=540670)
- [A nurse is caring for a client with acute lymphoblastic leukemia (ALL) who has been receiv…](https://mymerci.kr/pages/nclex_q.php?qn_id=540671)
- [A nurse is assessing a 65-year-old patient newly diagnosed with acute lymphoblastic leukem…](https://mymerci.kr/pages/nclex_q.php?qn_id=540672)
- [A nurse is caring for a 12-year-old child with acute lymphoblastic leukemia (ALL) who has …](https://mymerci.kr/pages/nclex_q.php?qn_id=540673)
- [A nurse is caring for a patient with acute lymphoblastic leukemia (ALL) who has just compl…](https://mymerci.kr/pages/nclex_q.php?qn_id=540674)
- [A nurse is caring for a client with acute myeloid leukemia (AML) who has developed tumor l…](https://mymerci.kr/pages/nclex_q.php?qn_id=540675)
- [The nurse must identify the most critical safety measure for a leukemia patient undergoing…](https://mymerci.kr/pages/nclex_q.php?qn_id=540677)

---

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

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