A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care?

Reference Range:

Platelet Count [150,000 to 400,000/mm3 (156 400 x 109/L)]

A) Incorrect- Observing for swelling at the fracture site is important for assessing the client's musculoskeletal condition, but it is not the priority intervention in this situation. The absence of spontaneous respirations and palpable carotid pulse indicates cardiac arrest, and immediate intervention is needed.

B) Incorrect- Analyzing the cardiac rhythm in another lead is not the first priority when the client is in cardiac arrest. Cardiopulmonary resuscitation (CPR) should be initiated immediately to restore circulation.
C) Incorrect- Obtaining a 12-lead electrocardiogram is not the initial intervention in a client in cardiac arrest. CPR and defibrillation (if indicated) are the immediate actions to provide circulation and oxygenation to the vital organs.
D) Correct- The absence of spontaneous respirations and palpable carotid pulse indicates cardiac arrest. In this situation, immediate initiation of cardiopulmonary resuscitation (CPR) is critical to provide circulation and oxygenation to the vital organs. Chest compressions are the initial step to address cardiac arrest and ensure blood flow to the body.

Given the client's symptoms of constant chest pressure that is unrelieved with rest, along with the client's appearance of anxiety, pallor, and diaphoresis, it indicates a high likelihood of an acute coronary event, such as a myocardial infarction (heart attack). In this situation, the nurse should prioritize immediate actions that address the potential cardiac emergency.

Aspirin is an essential medication in the initial management of acute coronary syndrome, including unstable angina and myocardial infarction. It helps to inhibit platelet aggregation and reduce the risk of clot formation in the coronary arteries. The chewable form of aspirin is recommended because it allows for more rapid absorption.

While evaluating extremities for perfusion, pulse volume, and pitting edema is important in assessing the client's overall cardiovascular status, it is not the immediate next step when faced with a suspected acute coronary event.

Securing client consent for coronary angiography and percutaneous coronary intervention (PCI) is a relevant step in the management of unstable angina and myocardial infarction, but it is not the immediate action to be taken in the emergency department. The client requires stabilization and initial medical interventions before procedural consent can be obtained.

Placing an indwelling urinary catheter and instituting strict intake and output measurements is not a priority action in this situation. The focus should be on addressing the potential acute coronary event and ensuring the client's cardiac stability. Urinary catheterization and monitoring of intake and output can be considered later, if necessary.