The nurse is caring for a 16-year-old boy with acute myelogenous leukemia who is having chemotherapy and who has incomplete records for varicella zoster immunization. Which is the priority nursing diagnosis?
A) Pain related to adverse effects of treatment verbalized by the child
B) Nausea related to side effects of chemotherapy verbalized by the child
C) Constipation related to the use of opioid analgesics for pain
D) Risk for infection related to neutropenia and immunosuppression
Ans: D
The priority nursing diagnosis is risk for infection related to neutropenia and immunosuppression. The incomplete records for varicella zoster immunization can cause a problem since exposure to chickenpox could cause sepsis, so the nurse should contact the oncologist for approval to administer the vaccine. Certain vaccines are not administered when the child is immunosuppressed, so timing is crucial. Diagnoses for pain and nausea are valid for this child because he is undergoing chemotherapy, but they are not a priority. Likewise, the need for constipation management would not be necessary unless opioid use begins.
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