The nurse is assessing a client with a history of heart failure who reports new-onset dyspnea and fatigue. Which finding requires the most immediate intervention?

Choice A reason: A red blood cell count of 3.5 x 10⁶/µL indicates anemia from myelosuppression, reducing oxygen transport. RBCs do not fight infection, so this does not support “risk for infection.” Low WBCs impair immune defense, increasing infection susceptibility, making WBC count more relevant to the nursing problem in this context.

Choice B reason: A WBC count of 1,500/mm³ indicates severe leukopenia from myelosuppression, reducing neutrophil production. This impairs immune response, significantly raising infection risk, as pathogens overwhelm the body’s defenses. This lab value directly supports “risk for infection,” necessitating precautions like isolation or antibiotics to prevent opportunistic infections.

Choice C reason: Hematocrit of 33% reflects anemia in myelosuppression, lowering oxygen delivery. This causes fatigue but does not increase infection risk, as RBCs are not immune cells. WBCs, particularly neutrophils, are critical for infection defense, making low WBC count more relevant to the nursing problem than hematocrit.

Choice D reason: Hemoglobin of 10 g/dL indicates anemia, reducing oxygen-carrying capacity in myelosuppression. This does not directly increase infection risk, as hemoglobin is not involved in immunity. Low WBCs compromise pathogen defense, making WBC count the key value supporting “risk for infection” in this client’s care plan.

Choice A reason: Assessing blood return checks patency, but pain suggests infiltration or phlebitis, where saline leaks into tissues. Stopping the infusion prevents further tissue damage, as extravasation causes swelling or necrosis, especially in dehydrated elderly clients, making assessment secondary to halting infusion.

Choice B reason: Stopping the saline infusion is the priority, as pain at the IV site suggests infiltration or phlebitis, with fluid irritating tissues or veins. Halting infusion prevents damage, allowing safe assessment and management, critical in fragile elderly veins, ensuring no further harm during rehydration.

Choice C reason: Establishing new IV access is necessary post-infiltration but not first. Pain indicates ongoing tissue irritation from saline leakage, requiring immediate infusion cessation to prevent damage. Stopping the infusion ensures safety before reattempting access, critical in dehydrated patients needing fluid replacement.

Choice D reason: Selecting a different gauge needle is irrelevant, as the 24-gauge catheter is placed, and pain indicates infiltration, not size. Stopping the infusion prevents extravasation, which risks compartment syndrome in elderly clients, making this less immediate than halting the infusion for safety.