A patient with cancer is receiving chemotherapy which has resulted in thrombocytopenia. What action will the nurse prioritize most in the nursing cancer plan?

1. A

   Ambulation three times daily

2. B

   Assessment of temperature

3. C

   Monitoring platelet count

4. D

   Monitoring for pathological fractures

Appeared in: Uttarakhand CHO - 2021

Explanation

• Thrombocytopenia is a condition of low platelet count, which is the primary cause of bleeding in cancer patients.
• The most critical nursing priority is to assess the severity of the thrombocytopenia to determine the risk of bleeding.
• Monitoring the platelet count is the direct and most accurate method to quantify this risk.
• The results of the platelet count guide all subsequent nursing interventions, such as implementing bleeding precautions or preparing for a platelet transfusion.

Why Other Options Were Wrong

• Option A: Ambulation is not the priority and could be dangerous. If the platelet count is critically low, a fall could cause a fatal hemorrhage. Safety from bleeding is the primary concern.
• Option B: Assessing temperature is the priority for neutropenia (low white blood cell count) due to the high risk of infection. The question specifies thrombocytopenia (low platelet count), where the primary risk is bleeding.
• Option D: Pathological fractures are related to bone integrity issues, such as bone metastases or osteoporosis, not directly to a low platelet count.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Nursing priority for a patient with chemotherapy-induced thrombocytopenia to guide bedside assessment, documentation, and the next nursing action.
• Nurses must implement bleeding precautions for patients with thrombocytopenia. This includes using a soft-bristled toothbrush, avoiding intramuscular injections and rectal temperatures, using an electric razor, and preventing falls.
• It is crucial to monitor the patient for subtle signs of bleeding, such as petechiae (pinpoint red spots), ecchymosis (bruising), and blood in urine or stool.
• What if? If the patient's platelet count dropped below 10,000/mm³, the priority would escalate to preventing spontaneous hemorrhage, which might involve strict bed rest and preparing for an imminent platelet transfusion.

How to Approach the Question

• First, identify the core clinical problem presented in the question stem, which is 'thrombocytopenia' resulting from chemotherapy.
• Recall the primary pathophysiology and risk associated with thrombocytopenia: platelets are for clotting, so a low count means a high risk of bleeding.
• Analyze the question's requirement: to identify the 'most prioritized' nursing action. This means finding the foundational assessment or intervention that guides all other care.
• Evaluate each option against the primary risk of bleeding. 'Monitoring platelet count' is the direct assessment of this risk.
• Eliminate the other options by linking them to different clinical problems: 'Assessment of temperature' is for infection risk (neutropenia), 'Monitoring for pathological fractures' is for bone integrity issues, and 'Ambulation' is a secondary intervention that depends on the patient's safety and bleeding risk.
• Conclude that monitoring the platelet count is the priority because it quantifies the risk and dictates the necessary safety precautions.

Concept Tested & Keywords

• Concept Tested: Nursing priority for a patient with chemotherapy-induced thrombocytopenia.
• Stem keywords: cancer, chemotherapy, thrombocytopenia, nursing care plan
• Lead-in keywords: prioritize most
• Clinical cues: The patient has thrombocytopenia, which is the key condition guiding the priority action.

Question ID

QB1jitLhJpvCpMRh5tt450

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 3 pp. 39-41, 7-9

E6 Pharmacology Nursing Lilley 11e Part 3 p. 89-91