A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?

Choice A Reason:
Monitoring the CXR (chest X-ray) results is not directly related to assessing myelosuppression. A chest X-ray is typically used to evaluate the lungs and heart, and while it can help identify infections or other complications, it does not provide information about bone marrow activity or blood cell counts. Myelosuppression specifically affects the production of blood cells in the bone marrow, which is best assessed through blood tests like the CBC (Complete Blood Count).
Choice B Reason:
Monitoring the BMP (Basic Metabolic Panel), especially the sodium, potassium, and magnesium counts, is important for evaluating electrolyte balance and kidney function. However, it does not directly assess myelosuppression. Myelosuppression involves the suppression of bone marrow activity, leading to decreased production of blood cells, which is not reflected in electrolyte levels.
Choice C Reason:
Monitoring the CBC (Complete Blood Count), especially the neutrophil, platelet, and RBC (red blood cell) counts, is the most appropriate method for assessing myelosuppression. Myelosuppression results in decreased production of blood cells, including neutrophils (a type of white blood cell), platelets, and red blood cells. A CBC provides detailed information about these cell counts and helps identify conditions like neutropenia (low neutrophil count), thrombocytopenia (low platelet count), and anemia (low red blood cell count), which are common consequences of myelosuppression.
Choice D Reason:
Monitoring the spinal fluid analysis is not relevant for assessing myelosuppression. Spinal fluid analysis is typically used to diagnose conditions affecting the central nervous system, such as infections, bleeding, or multiple sclerosis. It does not provide information about bone marrow activity or blood cell counts, which are the primary concerns in myelosuppression.

Choice A: Collect patient information

The first step in the nursing process is to collect patient information, also known as the assessment phase. During this phase, the nurse gathers comprehensive data about the patient’s health status, including medical history, physical examination findings, and any relevant diagnostic test results. This information forms the foundation for identifying the patient’s needs and planning appropriate care.

Choice B: Identify any clinical problems

After collecting patient information, the next step is to identify any clinical problems, also known as the diagnosis phase. In this phase, the nurse analyzes the assessment data to determine the patient’s health issues or potential risks. This step involves critical thinking and clinical judgment to prioritize the patient’s problems and develop a nursing diagnosis.

Choice C: Decide a plan of action

The third step is to decide a plan of action, also known as the planning phase. During this phase, the nurse sets measurable and achievable goals for the patient’s care based on the identified clinical problems. The nurse also develops specific interventions to address these problems and achieve the desired outcomes. This plan serves as a guide for the subsequent implementation phase.

Choice D: Carry out the plan

The fourth step is to carry out the plan, also known as the implementation phase. In this phase, the nurse executes the planned interventions to address the patient’s clinical problems. This may involve administering medications, providing treatments, educating the patient and family, and coordinating care with other healthcare professionals. The nurse continuously monitors the patient’s response to the interventions and makes adjustments as needed.

Choice E: Determine whether the plan was effective

The final step is to determine whether the plan was effective, also known as the evaluation phase. During this phase, the nurse assesses the patient’s progress toward the established goals and evaluates the effectiveness of the interventions. If the desired outcomes are not achieved, the nurse may need to revise the plan and implement new strategies. This ongoing evaluation ensures that the patient’s care is continuously improved and optimized.