The patient with cancer is receiving chemotherapy and develops thrombocytopenia The nurse identifies which intervention as the highest priority in the nursing plan of care?

1. A

   Ambulation three times a day

2. B

   Monitoring a platelet count

3. C

   Monitoring temperature

4. D

   Monitoring for pathological factors

Appeared in: Chitranjjan National Cancer Institute Kolkata - 2021

Explanation

• monitoring the platelet count because thrombocytopenia, a low platelet level caused by chemotherapy, creates a significant risk for bleeding.
• The platelet count is the primary objective data used to assess the severity of thrombocytopenia and the patient's risk for hemorrhage.
• All other nursing interventions, such as implementing bleeding precautions, modifying activity levels, and preparing for potential transfusions, are guided by the results of the platelet count.
• Frequent monitoring of blood counts is essential to anticipate and manage toxicities from chemotherapy, with bleeding being the primary concern for thrombocytopenia.

Why Other Options Were Wrong

• Option A: Ambulation is not the highest priority and could be contraindicated. If the platelet count is critically low, the risk of a fall leading to a serious bleed outweighs the benefits of ambulation.
• Option C: Monitoring temperature is the highest priority for neutropenia (low white blood cell count) due to the risk of infection, not for thrombocytopenia.
• Option D: This option is too vague and not a specific, measurable nursing intervention. 'Pathological factors' is not a standard clinical term for a priority assessment in this context.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Prioritization of nursing care for complications of chemotherapy to guide bedside assessment, documentation, and the next nursing action.
• In clinical practice, recognizing the specific risks associated with each type of cytopenia is critical for patient safety. Nurses must prioritize assessments and interventions based on the most life-threatening risk.
• A key nursing role is implementing 'Bleeding Precautions' for patients with thrombocytopenia. This includes using a soft toothbrush, an electric razor, avoiding IM injections, and applying prolonged pressure to venipuncture sites.
• What if? If the patient with thrombocytopenia also developed a fever of 100.9°F (38.3°C), the nurse's priority would shift. While bleeding risk remains a concern, the fever suggests a possible infection in an immunocompromised state (neutropenia), which is an immediate life-threatening emergency. The priority would become obtaining blood cultures and administering antibiotics, alongside continued bleeding precautions.

How to Approach the Question

• First, identify the key terms in the question: 'chemotherapy,' 'thrombocytopenia,' and 'highest priority.'
• Recall the definition of thrombocytopenia: a low platelet count.
• Connect the pathophysiology to the primary clinical risk. The function of platelets is blood clotting, so a low count leads to a high risk of bleeding.
• Evaluate the options based on this primary risk. The question asks for the highest priority intervention, which will be the one that most directly assesses or manages the risk of bleeding.
• Option A (Ambulation) is an activity that could increase risk. Option C (Temperature) relates to infection (neutropenia), not bleeding. Option D (Pathological factors) is too vague.
• Option B (Monitoring platelet count) is the direct assessment of the severity of thrombocytopenia and therefore the level of bleeding risk. This makes it the foundational, highest-priority intervention that guides all other actions.

Concept Tested & Keywords

• Concept Tested: Prioritization of nursing care for complications of chemotherapy.
• Stem keywords: cancer, chemotherapy, thrombocytopenia, highest priority
• Lead-in keywords: highest priority
• Clinical cues: A patient with cancer receiving chemotherapy is a high-risk patient for myelosuppression.

Question ID

Qv4iGxAnb_wMhUS3zpT8vi

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 3 p. 7-9

E6 Pharmacology Nursing Lilley 11e Part 3 p. 93-95