An older woman with breast cancer has completed a course of external radiation and is receiving chemotherapy
After her recent chemotherapy treatment, she complains of severe weakness, dizziness, and leth-argy and is admitted to the hospital. Her platelet count is 45,000. Based on this scenario, what nursing intervention is of the highest priority?
a. Preventing falls
b. Maintaining skin integrity
c. Preventing infection
d. Replacing fluids
ANS: A
Fall prevention is the highest priority. The patient has at least two significant risk factors for falls (unsteady gait and complaints of dizziness). She has a platelet count of 45,000; a platelet count of less than 50,000 makes one at high risk for spontaneous bleeding. The nurse must observe for overt and covert bleeding. If the patient falls, she is very likely to have a significant injury be-cause of the low platelet count. Maintaining skin integrity would be important in this patient be-cause she has received external radiation, which can cause alterations in skin integrity, but this is not as high a priority. Although preventing infection is an important intervention in a patient with cancer who has received radiation and chemotherapy, there is no evidence that this patient has alterations in her laboratory values related to the treatments, so fall prevention is more critical. There are no specific indications that this patient is experiencing a fluid deficit.
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