Difficulty: Medium
Average Score: 72%
Simulated
The nurse assesses the client diagnosed with acute myeloid leukemia. Which finding should be the nurseÔÇÖs priority for implementing interventions?
Correct answer
A
Rationale
A. Pain control is priority. The altered VS (other than temperature) could be related to pain. B. Weakness and fatigue are due to anemia and also the disease process. It is important to allow rest, but if pain is not controlled the client may not be able to rest. C. The temperature warrants further monitoring because it could indicate a developing infection; the other VS may decrease if pain is controlled. D. Ecchymosis and petechiae are associated with low platelet counts. The nurse should check the laboratory report for the platelet level, but this is an assessment and not an intervention.